Colorectal Cancer Disparities Research Articles

Colorectal cancer screening: The costs and benefits of getting to 80% in every community

Mailed fecal immunochemical testing (FIT) kits for colorectal cancer screening at home can contribute to reaching national goals of 80% colorectal cancer screening in communities. Policies that support cost‐effective colorectal cancer screening programs would decrease colorectal cancer disparities.

Improving Colorectal Cancer Screening in a Rural Setting: A Randomized Study

Colorectal cancer screening has been shown to prevent or detect early colorectal cancer and reduce mortality; yet, adherence to screening recommendations remains low, particularly in rural settings. RCT. Adults (n=7,812) aged 50-75 years and due for colorectal cancer screening in a largely rural health system were randomly assigned to either the intervention (n=3,906) or the control (n=3,906) group in September 2016, with analysis following through 2018. A mailed motivational messaging screening reminder letter with an option to call and request a free at-home fecal immunochemical screening test (intervention) or the standard invitation letter detailing that the individual was due for screening (control). Multifaceted motivational messaging emphasized colorectal cancer preventability and the ease and affordability of screening, and communicated a limited supply of test kits. Colorectal cancer screening participation within 6 months after mailed invitation was ascertained from the electronic medical record. Colorectal cancer screening participation was significantly improved in the intervention (30.1%) vs the usual care control group (22.5%; p<0.001). Individuals randomized to the intervention group had 49% higher odds of being screened over follow-up than those randomized to the control group (OR=1.49, 95% CI=1.34, 1.65). A total of 13.2 screening invitations were needed to accomplish 1 additional screening over the usual care. Of the 233 fecal immunochemical test kits mailed to participants, 154 (66.1%) were returned, and 18 (11.7%) tested positive. A mailed motivational messaging letter with a low-cost screening alternative increased colorectal cancer screening in this largely rural community with generally poor adherence to screening recommendations. Mailed colorectal cancer screening reminders using motivational messaging may be an effective method for increasing screening and reducing rural colorectal cancer disparities.

Impact of COVID-19 on colorectal cancer disparities and the way forward

In response to the coronavirus disease 2019 (COVID-19) pandemic, the U.S. Surgeon General advised all hospitals and ambulatory care centers to delay nonurgent medical procedures and surgeries. This recommendation, echoed by a multigastroenterology society guideline, led to the suspension of colonoscopies for colorectal cancer (CRC) screening and surveillance. Although this temporary suspension was necessary to contain COVID-19 infections, we as gastroenterologists, patient advocates, and CRC researchers have witnessed the downstream impact of COVID-19 and this recommendation on CRC screening, research, and advocacy. These effects are particularly noticeable in medically underserved communities where CRC morbidity and mortality are highest. COVID-19–related pauses in medical care, as well as shifts in resource allocation and workforce deployment, threaten decades worth of work to improve CRC disparities in medically underserved populations. In this perspective, we present the unique challenges COVID-19 poses to health equity in CRC prevention and provide potential solutions as we navigate these uncharted waters.

Abstract C123: The San Francisco Cancer Initiative: Addressing disparities in colorectal cancer screening in community health centers

Abstract Background: Despite being among the wealthiest cities in the United States, San Francisco continues to suffer from disparities in colorectal cancer (CRC) screening and diagnostic follow up among low-income and ethnically diverse residents served by community health centers (CHCs). The San Francisco Cancer (SF CAN) Initiative, a collaborative effort to reduce cancer in San Francisco, is dedicated to decreasing these and other cancer-related disparities. Purpose: To describe the approach and preliminary outcomes of the SF CAN’s CRC Task Force. Methods: Using principles of community engagement and implementation science, we developed a logic model to address CRC screening disparities. As inputs, the logic model features a partnership with the San Francisco Community Clinic Consortium (SFCCC) and its partner nonprofit community health centers. The goal is to increase screening with fecal immunochemical testing (FIT) and when needed, follow up colonoscopy, for its patient population. Continuous program evaluation utilizes the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework. Results: The SFCCC has created a quarterly reporting system to track CRC screening rates and facilitate collaborative goal setting for its partner CHCs. Six SFCCC clinical sites serving 18,815 adults aged 50-75 have used SF CAN’s technical assistance and Quality Improvement Stipends (QIS) to engage in an analysis of barriers and facilitators to screening and implement multi-level evidence-based interventions tailored to their identified specific needs. Barriers include low literacy, language, economic, and social obstacles to CRC screening such as lack of transportation or reliable access to housing or a private bathroom. The Task Force has assisted with staff training, patient education materials, and strategies for FIT distribution and collection. We have helped several sites switch from multi-sample FIT kits to evidence-based, user-friendly single sample FIT, and encouraged the development of tracking and navigation systems for abnormal FIT. In the first six months of QIS program, 5,199 patients were provided with FIT, and 3,932 (75.6%) successfully completed it. In addition, a first-ever review of 298 patients with abnormal FIT at these sites revealed that only 144 (48%) completed colonoscopy within 6 months, a finding that may lead to new initiatives to improve patient navigation. Additional SFCCC clinical sites will join the QIS program in the coming year. Conclusion: The SF CAN CRC Task Force has provided a model of academic and community partnership through which interventions to address CRC screening disparities in medically underserved communities can be implemented. Citation Format: Robert Hiatt, Carly Rachocki, Michael B. Potter, Ma Somsouk, David Ofman. The San Francisco Cancer Initiative: Addressing disparities in colorectal cancer screening in community health centers [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C123.

Abstract B103: Racial and geographic disparities in stage of presentation in the colorectal cancer hotspot region of North Carolina

Abstract Background: Despite improvements in colorectal cancer (CRC) screening, treatment, and long-term outcomes, recent epidemiological studies have demonstrated that geographic disparities in CRC persist. Spatial mapping has identified distinct hotspots of increased CRC death rates, including 11 rural counties in eastern North Carolina (NC). The primary aim of this study was to (1) measure CRC incidence by stage in the NC hotspot and non-hotspot regions, and (2) determine if racial disparities exist in stage-stratified incidence and overall mortality rates by geographic region. Methods: CRC diagnosis and death data from 2008-2016 were obtained from the NC Central Cancer Registry and analyzed by hotspot and non-hotspot regions by summary cancer stage at diagnosis and race. The non-hotspot region was defined as 71 NC counties outside of eastern NC. Death rates (95% CI) were expressed per 100,000 person-years and age-adjusted to the 2000 U.S. standard population. Regional rates were calculated for the 8-year interval. Results: Within the hotspot region in eastern NC, the overall incidence rate of CRC is higher than non-hotspot NC [43.7 (95% CI 39.2-48.8) vs 38.4 (95% CI 37.6-39.2)]. Within the hotspot counties, overall incidence rates are higher among African American (AA) compared to White patients [51.1 (95% CI 43.4-59.9) vs. 39.1 (95% CI 33.6-45.4)], and this disparity persists across all stage categories. The incidence among AA and White patients with localized disease is 18.4 and 14.4, respectively; for regional disease, 16.7 vs. 13.9; and for distant disease, 11.4 and 7.8. Similar racial disparities in CRC incidence are also observed within the non-hotspot counties (localized 16.1 vs. 13.5, regional 15.2 vs. 13.5, and distant 11.3 vs. 7.8). CRC mortality rates in the hotspot counties are higher among both AA and White patients (21.7 and 15.5, respectively) compared to non-hotspot NC (19.1 and 12.8, respectively), although the absolute difference by race is similar (6.2 vs. 6.3, respectively). Conclusions: Patients residing within the 11 rural hotspot counties in NC have higher age-adjusted incidence of localized, regional, and distant CRC and higher mortality rates than patients in non-hotspot counties. Noteworthy racial disparities exist in both stage at presentation and mortality rates; however, absolute racial disparities appear similar in both geographic regions. Future work should investigate the underlying etiology for both increased CRC incidence and mortality among AA and White patients in the NC hotspot counties. Citation Format: Tyler Hinshaw, Suzanne Lea, Justin Arcury, Alexander A Parikh, Rebecca A Snyder. Racial and geographic disparities in stage of presentation in the colorectal cancer hotspot region of North Carolina [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B103.

Abstract C066: Epigenetics and inflammatory environment may contribute to racial disparities in colorectal cancer

Abstract Colorectal cancer (CRC) mortality rates dropped by half in the past three decades, but CRC continues to demonstrate racial disparities in incidence and survival. It is believed that unfavorable socioeconomic conditions may lead to an inflammatory phenotype. Furthermore, epigenetic events play a major role in regulating inflammatory genes that have been linked to CRC health disparities. The objective of the study was to identify gene(s) that are dysregulated in CRC using The Cancer Genome Atlas (TCGA) database, and, furthermore, to characterize those genetic event(s) that are associated with CRC health disparities. The Engrailed-2 (En2) gene encodes for a homeobox-containing transcription factor regulating embryonic brain development. The data indicate that Nanog, IL-8, and EN2 were upregulated in colorectal cancer. EN2 was highly expressed in CRC stem cells and cell lines but its expression was very low or absent in normal cells. EN2 gene was highly expressed in CRC tissues derived from African American patients compared to those from Caucasian Americans. The expression of EN2 significantly increased with patients' age. There was no difference in EN2 expression between males and females of CRC patients. Higher expression of EN2 was correlated with poor survival of CRC patients with greater IL-8 expression. EN2 may act as a novel prognostic biomarker for CRC. Our data indicate that CRC disparities may be associated with epigenetic factors regulating the inflammatory environment. Citation Format: Y.M. Ma, S.K. Roy, R.K. Srivastava, S. Shankar. Epigenetics and inflammatory environment may contribute to racial disparities in colorectal cancer [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C066.

Abstract C036: Cohesins and colorectal cancer (CRC): Modulation of CRC stem cells and chemoresistance by STAG1 with race-specific implications

Abstract Despite advances in treatment and early detective measures for colorectal cancer (CRC), African-Americans (AAs) suffer disproportionately from CRC (~25% higher incidence and ~50% higher mortality) than Caucasians. Furthermore, AAs tend to receive earlier diagnoses in CRC and AA CRCs with high-grade differentiation were 3xs more likely to die within 5 yrs post-surgery as compared to whites (Alexander et al., Cancer 2005). The underlying mechanisms behind this more aggressive disease in AAs are poorly understood. Tomassati and Vogelstein postulate stem cell division correlates with risk of cancer (Science 2015). Addressing disease progression/aggressiveness, CRC stem cell markers are linked to chemoresistance; stem cell markers LGR5 and ALDH1a are established CRC stem cell markers. We have shown that the cohesin family member STAG1, a chromatin remodeler, is lost in the colonic epithelium of patients with premalignant lesions and AAs had a more profound loss (Cancer Prev Research 2016) through AA-specific STAG1 SNPs (Neoplasia 2018) and hypothesize that STAG1 loss is associated with poorer prognosis. Therefore, we wanted to investigate if STAG1 loss may lead to CRC stem cell induction as a potential mechanism of the racial disparities in CRC. RNA from rectal biopsies from 100 patients undergoing screening colonoscopies was processed for real-time PCR for CRC stem cell markers LGR5 and ALDH1a, as well as STAG1. To determine chemoresistance, STAG1 siRNA was transfected in CRC cell line HT29 and a CRISPR transfection of STAG1 SNP rs34149860 (found only in AAs) was transfected in CRC cell line RKO (possessing wildtype to SNP). Cell were treated with 5-FU and oxaliplatin and subjected to Annexin V Assay. Real-time PCR and analysis of STAG1 and CRC stem cell markers were performed for causation. AAs harboring neoplasias displayed a more robust loss of STAG1 mRNA (~50%, p&amp;lt;0.007) vs Caucasians with neoplasias (~25%, p=0.1). In regard to CRC stem cell markers, AAs with adenomas showed a stronger increase of LGR5 (67%, p=0.14), and ALDH1a (73%, p&amp;lt;0.007) vs Caucasians with neoplasias (LGR5 increased 59%, p=0.2; ALDH1a increased ~47%, p&amp;lt;0.05). HT29 cells transfected with STAG1 siRNA showed 30% less apoptotic response to 5-FU vs scramble vector and a marked 74% less response with oxaliplatin. CRIPSR SNP transfection in RKO showed similar effects, with a 2-fold less apoptotic response to 5-FU and &amp;gt;90% less response to oxaliplatin. PCR showed RKO STAG1-SNP transfected cells displayed a loss of STAG1(~40%, p&amp;lt;0.05) and an upregulation of LGR5 (~50%, p&amp;lt;0.05) and ALDH1a (~30%, p&amp;lt;0.05). This shows, for the first time, that STAG1 loss is implicated in colon carcinogenesis through potentiation of cancer stem cells through early carcinogenesis/initiation as well as disease progression and aggressiveness as shown through chemoresistance. Our work provides a potential mechanism in CRC, thus providing a biomarker for cancer screening and therapeutics that could mitigate the racial disparity of CRC in AAs. Citation Format: Mart Dela Cruz, Caroline Zaworski, Somenath Datta, Sanjib Chowdhury, Hemant K. Roy. Cohesins and colorectal cancer (CRC): Modulation of CRC stem cells and chemoresistance by STAG1 with race-specific implications [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C036.

Abstract B060: Health disparities and the molecular genomics of colorectal cancer by ancestry: The translational impact on colorectal cancer screening, surveillance, and treatment

Abstract Background: African Americans with colorectal cancer (CRC) have significantly worse outcomes than Caucasians with higher incidence, later stage at presentation, and worse overall survival. Even when controlling for socioeconomic status and stage at presentation, African Americans compared to Caucasians have a poorer response to medical therapy. We hypothesized that African Americans with colorectal cancer have a distinct genomic mutational profile that explains the observed differences in the natural history and response to treatment. Furthermore, self-reported data on race are imprecise, especially in individuals of mixed race as often found in under-represented communities. Methods: Using unpublished data from The Cancer Genome Atlas (TCGA), we utilized genomic data to accurately capture a person's ancestry (i.e., European, African, Asian). For each patient with CRC, we used a microarray of single-nucleotide polymorphisms (SNPs) and matched their genome with the publicly available 1000 Genomes project, which is a well-characterized database of the major world populations. Each individual's self-reported race was reclassified using a microarray of their SNPs using Ancestry Informative Markers with Principal Component Analysis. After genotypically defining each individual's ancestry, we studied differences in their somatic mutational profiles. To determine somatic mutational variations, we utilized MuTect2 software to study whole-exome sequencing data of the tumor and normal tissue. The functional impact of each mutation was then classified as high or low. Somatic mutation results were separated based on mutation type (e.g., single-nucleotide variants or insertions/deletions). Mutation-specific tables were separated by genotypically defined race. Permutation analysis was performed using 1000 random samplings to determine whether the observed gene frequency for each race was statistically significant (p &amp;lt;0.05). Results: 633 patients with colorectal cancer were analyzed and their baseline characteristics were: females (62%), self-reported African Americans (10%) and Caucasians (47%), stage III/IV (35%) and proximal CRC (50%). Preliminary data reveal unique somatic mutations that were distinct in individuals from African ancestry with specific genes playing key roles in oncogenesis. Additional data, including genotypically defined ancestry and somatic mutational differences, will be reported at the time of the conference. Conclusions: To our knowledge, this is the first application of ancestry informative markers using whole-exome sequencing to study health disparities in colorectal cancer. Differences in tumor mutational profiles may help explain disparities in outcomes between individuals of European and African ancestry. Citation Format: Taylor Thompson, John Greally, Parvathi Myer. Health disparities and the molecular genomics of colorectal cancer by ancestry: The translational impact on colorectal cancer screening, surveillance, and treatment [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B060.

Abstract B137: Colorectal cancer mortality and disparities in America’s 30 most populous cities

Abstract Background: In the U.S., colorectal cancer (CRC) is the 2nd leading cause of cancer deaths and Blacks have a 40% higher CRC mortality rate compared to Whites. Reduction in CRC mortality and racial disparities may be achieved, in part, by addressing modifiable factors (e.g. smoking, overweight/obesity, cancer screening availability/uptake, treatment access) and coordinating efforts by civil societies, policy makers, and community leaders. Implementing programs and policy changes at the city level may be the most effective strategy for the U.S. because over 80% of invasive cancer cases occur within urban areas. The purpose of the present analysis is to calculate (and rank) overall and race-specific CRC mortality rates as well as measures of disparities for the 30 biggest U.S. cities. Methods: The 2013-2017 National Center for Health Statistics mortality data and 2013-2017 American Community Survey 5-year population estimates were used to compute the overall, non-Hispanic (nH) Black, and nH White average annual CRC mortality rates for the U.S. and the 30 most populous cities. The rates were age-adjusted using the 2000 standard U.S. population. The Black and White CRC mortality rates were used to calculate rate ratios (RR) and rate differences (RD) and their respective 95% confidence intervals (CIs). In addition, the number of excess deaths due to the racial disparity in CRC mortality was ascertained. Results: The estimated annual CRC mortality rate for the U.S. was 14.3 per 100,000 total population. The city-level rates ranged from a low of 10.6 (San Jose) to a high of 31.1 (Las Vegas). Nationally, the Black rate was 43% higher than the White rate (95% CI: 1.41-1.44) with a RD of 6.27 per 100,000 population. Racial disparities were found in 25 of the 30 cities. Among those with a disparity, Philadelphia had the lowest level (RR=1.21; 95% CI 1.08-1.35, RD=3.55; 95% CI: 1.46-5.63) while Washington DC had the highest (RR=2.60; 95% CI 2.04-3.30, RD=13.65; 95% CI: 10.76-16.54). In the U.S., the yearly number of excess Black CRC deaths was 2,252. Across the 25 cities with a disparity, Seattle and Portland fared the best while Chicago fared the worst in terms of excess deaths (3 versus 96, respectively). Even among the 12 cities with a lower CRC mortality rate than that of the U.S., 7 had a greater level of disparity (RR&amp;gt;1.43) than the nation. However, some cities like San Diego, New York, Boston, and Oklahoma City fared well in terms of the overall CRC mortality rates and level of disparity. Conclusion: To our knowledge, this study is the first to illustrate the substantial variability in CRC mortality disparities across a sample of urban cities. Local level data helps identify cities that may need the most support and offers examples of model cities. City-level information can be used to assist city officials, public health professionals, cancer control agencies, and other organizations to make real, evidence-based changes in policies, services, and funding. Citation Format: Abigail Silva, Nazia Sayad, Fernando De Maio, Maureen Benjamins. Colorectal cancer mortality and disparities in America’s 30 most populous cities [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B137.

Abstract A125: The impact of the 2010 Patient Protection and Affordable Care Act (ACA) on colorectal cancer screening in vulnerable populations: A systematic literature review

Abstract Background: Disparities have existed and continue to exist in colorectal cancer (CRC) screening. Disparities in screening are correlated with other factors including educational attainment, healthcare access/insurance, and family history knowledge. These factors impact different vulnerable communities differently. This paper explores the impact of the 2010 Patient Protection and Affordable Care Act (ACA) on CRC screening rates and disparities in the United States. Methods: A comprehensive systematic literature review conducted in June 2019 revealed 47 published articles that explore the impact of the ACA on CRC screening. Results: The ACA affected CRC screening primarily in three ways: 1) costs associated with screening and diagnostic follow-up were reduced among commercially-insured patients, removing financial barriers; 2) uninsured, non-Medicaid-eligible individuals were able to gain access to healthcare services such as CRC screening through insurance plans purchased through health exchanges; and 3) vulnerable and high-risk populations gained access through the expansion of and changes to Medicaid in 32 states. These three pathways reduced screening disparities between various ethnic and racial populations, yet disparities remain. Conclusions: The ACA expanded access to screening and treatment efforts in order to decrease cancer incidence, increase early detection, decrease costly CRC management, and extend life expectancy for CRC survivors. Yet, the limited literature shows mixed results in terms of the ACA’s impact, especially in its initial phase. While screening technologies and systemic changes by the ACA have made significant progress in reaching high-risk and vulnerable populations including ethnic and racial minorities, there is still a concerning gap in both access to CRC screening services and the associated disparities in mortality. Future research should focus on delayed impacts of the ACA. Citation Format: Joshua S Yudkin, V. Paul Doria-Rose. The impact of the 2010 Patient Protection and Affordable Care Act (ACA) on colorectal cancer screening in vulnerable populations: A systematic literature review [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A125.

Abstract B100: Reported barriers to colorectal cancer screening in Appalachian Kentucky

Abstract Background: Appalachian Kentucky residents suffer significant colorectal cancer (CRC) disparity, in part related to low utilization of CRC screening. Reducing or removing potential barriers to CRC screening uptake may increase utilization of CRC screening in this population. The purpose of this study was to identify barriers to CRC screening in adults aged 50 years and older in rural Appalachian Kentucky. Methods: This study reports the analysis of baseline data from a randomized controlled trial designed to promote CRC screening in rural Appalachian Kentucky among individuals who have not been screened for CRC recruited from two Emergency Departments at St. Claire Regional Medical Center in Morehead, Kentucky, and Appalachian Regional Healthcare in Hazard, Kentucky. The survey used for this study assessed CRC screening status, barriers, susceptibility, and benefits related to CRC screening, sociodemographic characteristics, and other health-related information such as health care utilization including the reason for ED visit, insurance coverage, and health care access. Descriptive and bivariate analyses are reported. Results: Questionnaires were completed by 191 adults aged 50 and over, waiting for nonurgent care or with a family member in the ED of rural Appalachian hospitals. Participants were mostly Caucasian (98%), female (57%), aged 58 ± 8 years, who had household income &amp;lt; $20,000 (56%), and 95% had never undergone CRC screening. Fear of CRC result (51%), perceived pain (50%), and cost (49%) were the most salient barriers to CRC screening test. The following four demographic variables were significantly associated with barriers to CRC screening; education, marital status, income, and age. Conclusions: Rural Appalachian Kentucky residents do not screen for CRC according to guidelines, partly due to perceived barriers to CRC screening. Education and income level were associated with the perception of painful and costly CRC screening in this population, suggesting that they do not have adequate knowledge or access to CRC screening resources available in the communities. Considering the cultural norms peculiar to Appalachian Kentucky, this population will benefit from a community health worker-led educational intervention to promote CRC screening through short video messages about the CRC screening process, other less invasive screening options, and benefits of CRC screening. This intervention may be able to address the barriers identified in this group, including the perception of painful screening procedure and the fear of screening result. Additionally, appropriate navigation program to affordable and accessible CRC screening resources within the local community would be beneficial to addressing the dismal use of screening resources among individuals in this population. Citation Format: Adaeze Aroh, Adebola Adegboyega, Jennifer Hatcher. Reported barriers to colorectal cancer screening in Appalachian Kentucky [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B100.

Abstract B029: Community-based colorectal cancer screening initiative to address colorectal cancer disparities among African Americans and sexual and gender minorities on the Southside of Chicago

Abstract Background Colorectal cancer (CRC) persists as the second leading cause of cancer death and African Americans (AA) carry a disproportionate burden of CRC, having the highest incidence and mortality. Although CRC is one of the few cancers where screening can be prevention, AAs have lower uptake of CRC screening. Additionally, sexual and gender minorities (LGBTQ) are another population with growing CRC disparities. To date, few initiatives address CRC among LGBTQ populations. Factors impacting screening uptake among AA and LGBTQ populations are multi-factorial including access, awareness, and stigma. To attenuate low rates of CRC screening, the University of Illinois Cancer Center through funding from the Bristol-Myer Squibb Foundation has developed the UI CAAN (Cancer Screening; Access; Awareness; Navigation) Project. UI CAAN is a community focused cancer education, prevention, screening and navigation program aimed at addressing the elevated burden of CRC within the UI Cancer Center catchment population targeting 200 AA per year for three years. Methods Building upon the Center for Disease Control and Prevention socio-ecological model, UI CAAN will address multi-level barriers impacting CRC screening. The American Cancer Society recommends screening starting at age 45 using Fecal immunochemical tests (FITs). Community Lay navigators will work with barber shops, beauty/nail salons and venues frequented by members of the LGBTQ community to provide education and free FIT kits to AA on the Southside of Chicago. Participants who return their FIT kit will be compensated with a $25 Certificate for the barber or beauty salon or $25 gift card for those engaged through community venues. The project will partner with a Federally Qualified Health Center (FQHC) on the Southside of Chicago to support navigation for follow up. Results Year I is devoted to planning, priority setting and community engagement. The key community stakeholder for UI CAAN is Project Brotherhood, a non-profit community based organization with over two decades of successful engagement of AA communities. To date the project has identified a) A community health worker/lay patient navigator from the targeted community; b) identified and trained one barber and one beautician; c) identified and trained a community health psychologist to assist with program design and implementation and d) has identified two Community Health workers from the LGBTQ community in the target area. IRB approval has been obtained. Conclusion Completion of planning and priority setting of the UI CAAN Project to improve CRC screening among AA and LGBTQ populations on the Southside of Chicago demonstrate the feasibility of community engagement to plan and implement a community based CRC screening initiative. Phase II of Year I will begin August 2019 with screening and recruitment from a barber shop, beauty salon and key community events on the Southside of Chicago with navigation to a local FQHC. Citation Format: Karriem S Watson, Vida Henderson, Jessica Madrigal, Jeanette Gonzalez, Erica Martinez, Nasima Mannan, Tonya Roberson, Marcus Murray, Katherine Tossas-Milligna, Robert A Winn. Community-based colorectal cancer screening initiative to address colorectal cancer disparities among African Americans and sexual and gender minorities on the Southside of Chicago [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B029.

Abstract A014: Development of a culturally grounded brochure to enhance colorectal cancer screening in Southwestern American Indian communities

Abstract Elimination of colorectal cancer disparities is a national priority. Despite the effectiveness of colorectal cancer (CRC) screening tests for average risk adults, these tests are underutilized by American Indians/Alaska Natives. Subsequently, these populations have experienced either no change or an increase in CRC incidence. Prior to conducting a trial to determine the efficacy of interventions of graded intensity on screening behavior among six tribal communities in the Southwest United States, we set out to develop a culturally appropriate and theoretically grounded brochure to increase community demand for CRC screening. In order to ensure the brochure's health literacy to diverse tribal participants, we utilized the Suitability Assessment of Materials and Comprehensibility of Materials (SAM+CAM) instrument as a basis for structuring this process. Using an iterative process, we conducted two focus groups and made modifications to the brochure. We then implemented the SAM+CAM assessment. We report here on the findings from both the focus groups and the SAM+CAM testing. We organized focus group findings by the SAM+CAM categories, including content, literacy demand, numeracy, graphic material, layout/typography, and learning stimulation/motivation. We will provide quotes and summaries of the relevance for each of these SAM+CAM categories. By structuring focus groups with American Indian participants using these categories, we then made revisions to the brochure. The resulting SAM+CAM scores confirmed that the brochure was suitable and comprehensible to participants. Overall, the SAM+CAM scores were generally high as the overall rating was 90%, which indicates a superior product. Using this participatory and iterative process, we found that structuring the development and revision of the brochure through the SAM+CAM categories provided a useful process to balance the presentation of evidence-based data for CRC screening with community preferences and norms. Citation Format: Andrew L. Sussman, Kevin English, Matthew Frank, Dolores Guest, Deborah Helitzer, Shiraz Mishra. Development of a culturally grounded brochure to enhance colorectal cancer screening in Southwestern American Indian communities [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A014.

Geographic and demographic disparities in colorectal cancer: A population-based study.

e19047 Background: Colorectal cancer is one of the leading causes of cancer deaths in the US. Area of residence affects survival in many cancers, though largely unknown in colorectal cancer. The purpose of this study is to evaluate disparities between the metropolitan, urban and rural populations and the impact on survival in colorectal cancer. Methods: Data was obtained from the National Cancer Database (NCDB) colon, rectosigmoid, and rectal data sets. Patients (pts) were categorized by area of residence: metropolitan (MA), urban (UA), or rural (RA). Gender, race, insurance status, income, marital status, and tumor related data was collected. Univariate and multivariate analyses were performed to evaluate variables affecting overall survival (OS). Results: A total of 973,139 pts, spanning 2004-2013 were included in the study, 83% MA, 15% UA, 2% RA. RA and UA pts were more likely to be white than MA pts (92.7 v 91.4% v 83%). RA and UA were more likely to have lower income, with slightly lesser amounts of women and pts with no comorbidities. Uninsured rates were similar (3.3%). On univariate analysis, OS was worse for RA (HR 1.10) and UA (1.06) pts, as compared with MA. On multivariate analysis, small differences persisted with worse OS for RA (HR 1.02, p = .043) and UA (HR 1.01, p = .003). Black (HR 1.14) and native American (HR 1.17) pts had worse outcomes, while Asian (HR 0.8) pts had improved OS. Women (HR 0.88) and pts with higher incomes ( &gt; 46K or 63K) had improved OS (HR 0.88). Conclusions: This study identifies socio-demographic disparities in colorectal cancer outcomes. Pts from rural and urban areas had worse OS, even though the proportion of minority pts with poor outcomes was lower. The difference in OS for RA and UA remained statistically significant in multivariate analysis, though it was largely corrected when adjusting for influencing variables. Part of this difference may be due to economic disparities, as lower income was linked to worse OS. This can independently limit access to care, especially for geographically isolated individuals. Additional research efforts are needed in order for us to better understand the key issues facing and the optimal means to improve outcomes in at risk populations.

Racial and socioeconomic disparities in overall survival in colorectal cancer (CRC) at West Cancer Center &amp; Research Institute (WCCRI), Memphis, TN.

e16122 Background: WCCRI, a comprehensive regional community oncology center in Memphis, Tennessee and the Mid-South region, serves a racially, geographically and socioeconomically diverse patient cohort. We sought to evaluate disparity of outcomes in survival by race and socioeconomic status, in addition to patient and tumor characteristics. Methods: All consecutive patients referred to and treated at WCCRI with colorectal adenocarcinoma from 2007-2013 were included. Individual chart review was performed to verify diagnosis, stage, and date and cause of death. Kaplan-Meier Overall Survival curves were generated for the entire cohort and by race, sex, tumor location and income derived from zip code. WCCRI survival data were compared to SEER data. Results: From 2007-2013, 1,176 patients were included in the analysis: 405 blacks, 757 whites, 14 others. Median age at diagnosis: Blacks 58 yrs, whites 61 yrs. Stage distribution at diagnosis: stage 1: 100, stage 2: 275, stage 3: 425, stage 4: 376. All stages combined, blacks trended towards shorter OS vs whites (5-year OS: 52.8% vs 58.3%; median survival 71.0 mos vs 98.6 mos; p= 0.095). Blacks presented at later stages (71.4% at stage 3 or 4 vs 66.3% for whites) but no statistically significant OS differences were seen when compared by stage. Patients at or below the median income of $39,590 for WCC had worse 5-year OS (51.6% vs. 61.1%; p= 0.006), as did patients without private insurance (5-year OS: uninsured: 48.0%, Medicare/Medicaid: 50.0%, private: 62.0%; p&lt; 0.001). Adjusted for stage, 5-year OS was statistically significant for stage 4 (private: 18.0%, Medicare/Medicaid: 9.4%, uninsured: 8.3%; p= 0.020). A higher proportion of blacks were below the median income (69% vs 39%) but no statistically significant OS differences were seen when adjusted by race. Overall, cancer survival outcomes were similar to SEER results. Conclusions: At WCCRI, black patients with CRC presented at a later stage than whites, however, adjusted for stage, no significant racial difference in OS was found. Income and insurance status influenced survival outcomes. Overall, our results reveal racial and socioeconomic disparities in colorectal cancer in a diverse US population and further detailed multivariate data analyses are underway.

Racial disparities in colorectal cancer time-to-treatment and survival time in relation to diagnosing hospital cancer-related diagnostic and treatment capabilities

BackgroundThere is a need to understand structural issues, such as differential access to or utilization of technologies or capabilities, to better understand racial disparities in cancer outcomes. The objective of this work was to evaluate time-to-treatment and survival in relation to cancer-related diagnostic and treatment technologies of the diagnosing hospital. MethodsColorectal tumor-level data from George Cancer Registry was merged with hospital-level cancer technology data from the American Hospital Association (2010–2015). Cox proportional hazard models were used to model time-to-treatment and time-to-death following cancer diagnosis with cancer-related technologies for colon and rectosigmoid/rectal tumors, stratified by race and controlling for personal and tumor characteristics. ResultsBlack individuals experienced lower likelihood of treatment (HR: 0.92, 95 % CI: 0.89, 0.96) for colon tumors, but not significantly different survival (HR: 1.03, 95 % CI: 0.98, 1.09). Larger capacity or size indicators (total surgical operations, emergency room visits, and licensed beds) were associated with higher likelihood of treatment in whites, but not blacks. Higher counts of treatment related technologies were associated with better survival in whites (HR = 0.92, 95 % CI: 0.85, 0.99), but not blacks (HR: 1.07, 95 % CI: 0.95, 1.19). Virtual colonoscopy emerged as a technology related to survival favorably in whites (HR: 0.84, 95 % CI: 0.77, 0.92) and blacks (HR: 0.89, 95 % CI: 0.79, 1.00). Overall results were similar for rectosigmoid/rectal tumors as observed for colon tumors. ConclusionThe role of cancer-related technologies presence or utilization for colorectal cancer outcomes and potential racial disparities warrants further research.

Racial and socioeconomic disparities in overall survival in colorectal cancer (CRC) at West Cancer Center (WCC), Memphis, TN.

80 Background: WCC, a comprehensive regional community oncology center in Memphis, Tennessee and the Mid-South region, serves a racially, geographically and socioeconomically diverse patient cohort. We sought to evaluate disparity of outcomes in survival by race and socioeconomic status, in addition to patient and tumor characteristics. Methods: All consecutive patients referred to and treated at WCC with colorectal adenocarcinoma from 2007-2013 were included. Individual chart review was performed to verify diagnosis, stage, and date and cause of death. Kaplan-Meier Overall Survival curves were generated for the entire cohort and by race, sex, tumor location and income derived from zip code. WCC survival data were compared to SEER data. Results: From 2007-2013, 1,176 patients were included in the analysis: 405 blacks, 757 whites, 14 others. Median age at diagnosis: Blacks 58 yrs, whites 61 yrs. Stage distribution at diagnosis: stage 1: 100, stage 2: 275, stage 3: 425, stage 4: 376. All stages combined, blacks trended towards shorter OS vs whites (5-year OS: 52.8% vs 58.3%; median survival 71.0 mos vs 98.6 mos; p= 0.095). Blacks presented at later stages (71.4% at stage 3 or 4 vs 66.3% for whites) but no statistically significant OS differences were seen when compared by stage. Patients at or below the median income of $39,590 for WCC had worse 5-year OS (51.6% vs. 61.1%; p= 0.006), as did patients without private insurance (5-year OS: uninsured: 48.0%, Medicare/Medicaid: 50.0%, private: 62.0%; p&lt; 0.001). Adjusted for stage, 5-year OS was statistically significant for stage 4 (private: 18.0%, Medicare/Medicaid: 9.4%, uninsured: 8.3%; p= 0.020). A higher proportion of blacks were below the median income (69% vs 39%) but no statistically significant OS differences were seen when adjusted by race. Overall, cancer survival outcomes were similar to SEER results. Conclusions: At WCC, black patients with CRC presented at a later stage than whites, however, adjusted for stage, no significant racial difference in OS was found. Income and insurance status affected survival outcomes. Overall, our results reveal racial and socioeconomic disparities in colorectal cancer in a diverse US population.

Outcomes Among Minority Patients With Metastatic Colorectal Cancer in a Safety-net Health Care System

BackgroundMetastatic colorectal cancer (CRC) outcomes continue to improve, but they vary significantly by race and ethnicity. We hypothesize that these disparities arise from unequal access to care. Materials and MethodsThe Harris Health System (HHS) is an integrated health delivery network that provides medical care to the underserved, predominantly minority population of Harris County, Texas. As the largest HHS facility and an affiliate of Baylor College of Medicine’s Dan L. Duncan Comprehensive Cancer Center, Ben Taub Hospital (BTH) delivers cancer care through multidisciplinary subspecialty that prioritize access to care, adherence to evidence-based clinical pathways, integration of supportive services, and mitigation of financial toxicity. We performed a retrospective analysis of minority patients diagnosed with and treated for metastatic CRC at BTH between January 2010 and December 2012. Kaplan-Meier survival curves were compared with survival curves from randomized control trials reported during that time period. ResultsWe identified 103 patients; 40% were black, 49% were Hispanic, and 12% were Asian or Middle Eastern. Thirty-five percent reported a language other than English as their preferred language. Seventy-four percent of patients with documented coverage status were uninsured. Eighty-four percent of patients received standard chemotherapy with a clinician-reported response rate of 63%. Overall survival for BTH patients undergoing chemotherapy was superior to that of subjects enrolled in the CRYSTAL (Cetuximab Combined with Irinotecan in First-Line Therapy for Metastatic Colorectal Cancer) trial (median, 24.0 vs. 19.9 months; P = .014). ConclusionHHS provides a health delivery infrastructure through which minority patients with socioeconomic challenges experience clinical outcomes comparable with highly selected patients enrolled in randomized control trials. Efforts to resolve CRC disparities should focus on improving access of at-risk populations to high-quality comprehensive cancer care.

Colorectal Cancer: An Emphasis on Factors Influencing Racial/Ethnic Disparities.

Current statistics related to cancer incidence and cancer-related death rates clearly show that specific racial/ethnic minorities are more likely to be diagnosed and/or die with cancer. Colorectal cancer (CRC) is one of the leading causes of cancer deaths in the United States and it disproportionately affects the non-Hispanic Black or African American (AA) population. When compared to the non-Hispanic White (nHW) population, incidence and death rates in AAs are 28% and 60% higher, respectively. Hispanics have an overall lower CRC incidence rate than nHWs (Hispanics: 35.5 per 100,000 population; nHWs: 40.2 per 100,000 population), but their incidence continues to rise, unlike nHWs, who are experiencing a decline. This disparity between Hispanics and nHWs is further highlighted in the younger Hispanic population. While the cause of the disparities is associated with CRC-related genetic and environmental factors, the role of specific genes/mutations in each population are still not fully unraveled. However, because CRC is a slowly progressing disease, routine screening and/or early intervention are key to achieving better outcomes in CRC patients and ultimately in closing the disparity gap among different populations. This review discusses the major factors influencing the disparities in CRC and also focuses on factors such as treatment response, family history, and screening that potentially contribute to the racial/ethnic disparities in CRC.

Health care disparities in colorectal and esophageal cancer

Health care disparities in colorectal and esophageal cancer