Disparities In Colorectal Cancer Mortality Research Articles

EPH7 Racial Disparities in Colorectal Cancer Outcomes: How Community Health Workers Can Increase Screening Uptake in the US

Analyze and evaluate the impact of community health workers (CHW) in increasing colorectal cancer (CRC) screening for Black men. Secondly, to encourage private payers’ investment in robust screening programs that will reduce medium-to long-term costs, improve outcomes, and decrease racial disparities in CRC mortality.

Abstract PO-086: Social vulnerability related to rural disparities in colorectal cancer mortality in Florida

Abstract Introduction: The multiple rural and urban counties in the state of Florida exhibit different socioeconomic characteristics and access to healthcare. These differences in living conditions potentially impact incidence and mortality rates of diseases, particularly cancer. We examined rural differences in county-level colorectal cancer incidence and mortality and county social vulnerability characteristics related to rural disparities in colorectal mortality for all 67 counties in Florida. Methods: We examined colorectal cancer incidence and mortality data provided by the National Cancer Institute (NCI) State Cancer Profiles in conjunction with the United States Census Bureau definition for rurality: counties that have more than 50% of their population within a rural area would be classified as rural. We used a t-test for unequal variances to examine the difference in the mean colorectal incidence and mortality for rural counties compared to urban counties. We then used a linear regression to examine county social vulnerability (SoVI) metrics, poverty, and Medically Underserved Areas (MUA) related to colorectal cancer mortality. Preliminary Results: Of the 67 counties in Florida, 25 were designated as rural and 42 were designated as urban. The mean rural age-adjusted incidence of colorectal cancer was 40.93 per 100,000 compared to 36.82 per 100,000 for urban incidence (p=0.16). The rural mortality per 100,000 for colorectal cancer was significantly higher than urban colorectal morality per 100,000 (18.22 vs 13.12, p=<0.01). Our pending regression analysis will pinpoint county SoVI factors (such as poverty and MUA) specifically related to the observed disparity in rural colorectal cancer mortality. Conclusion: While risk of colorectal cancer was not significantly higher for rural counties in Florida, the rural colorectal death rate was significantly higher in rural than urban counties. These results add to the understanding of socioeconomic characteristics related to rural disparities in cancer mortality. Further work is needed to address strategies for eliminating rural disparities so that there is a greater chance of surviving diseases such as colorectal cancer. Citation Format: Alejandro Arroyo Rodriguez, Cassie Lewis Odahowski. Social vulnerability related to rural disparities in colorectal cancer mortality in Florida [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-086.

Disparities Among Limited English Proficient Patients in Colon Cancer Screening with Multi-target DNA Stool Test.

Racial and language minority groups in the U.S. are at a higher risk for morbidity and mortality from colorectal cancer (CRC), partially due to lower screening rates. This is a retrospective cohort study comparing successful multi-target stool DNA test (mt-sDNA) test completion among patients with limited English proficiency (LEP) and English proficient (EP) patients, from 2015 to 2018. Patients with LEP were frequency matched to EP patients by age at a 3:1 ratio. The percentage of mt-sDNA tests without useful results was 53% among patients with LEP compared to 29% among EP patients (p < 0.0001). The median number of days from order placement to test completion was 62.5 among patients with LEP compared to 33 for EP patients (p = 0.003). This study demonstrates a significant disparity in CRC screening completion using the mt-sDNA test among populations with LEP, which may widen existing disparities in CRC mortality.

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.

Racial Disparities in Colorectal Cancer Mortality: the Role of Endoscopy Wait-Time and Stage at Diagnosis.

In Western Washington (WA), colorectal cancer (CRC) mortality between 2012 and 2016 was highest in American Indian/Alaska Natives (AI/AN) and African-Americans (AA) at 20.7 and 18.7, respectively, compared with non-Hispanic Whites at 14.1/100,000 people. We hypothesized that time from billed encounters for CRC-associated symptoms to endoscopy completion or CRC stage at diagnosis contributed to observed differences. Using administrative insurance claims linked to WA cancer registry data, we performed a retrospective cohort study of patients diagnosed with CRC between 2011 and 2017, with continuous insurance for 15months prior to diagnosis and a billed encounter for CRC-associated symptoms. We determined the wait-time (days) and stage at diagnosis and conducted logistic regression analysis to identify the factors associated with endoscopy completion. Of the 3461 CRC patients identified, 57% had stage 2 or 3 disease with no differences in stage by race, and 84% completed an endoscopy after a billed encounter for CRC-associated symptoms. The median wait-time to endoscopy was 52days (IQR 14-218) without differences by race. Compared with patients diagnosed with stage 1 CRC, patients with stage 4 CRC were more likely to complete an endoscopy within the first quartile of time (22.2% vs. 17.4%, p< 0.01). Living arrangement, insurance type, and comorbidity, but not race, were significant factors associated with endoscopy completion. We found no statistically significant differences in time from billed CRC-associated symptoms to endoscopy completion or in CRC stage among AA and AI/AN compared to Whites. This suggests that other factors are more likely to contribute to observed mortality disparities.

Rural-urban disparities in colonoscopies after the elimination of patient cost-sharing by the Affordable Care Act

IntroductionImproving the prevention and early detection of colorectal cancer is a priority for reducing rural-urban disparities in colorectal cancer mortality. By eliminating out-of-pocket (OOP) costs for preventive colonoscopies, the Affordable Care Act (ACA) could have reduced rural-urban disparities in screening. MethodsWe used the Maine Health Data Organization All-Payer Claims Database including all commercially-insured and Medicare beneficiaries aged 50–75 between 2009 and 2012. Rural-urban commuting areas were used to classify rural/urban residence. ICD-9 and CPT codes identified colonoscopies. We summed all OOP payments per patient-day. An interrupted time series model estimated the impact of the ACA on trends in rural-urban disparities in colonoscopy rates and OOP costs. ResultsBefore the ACA, colonoscopy rates were 16% lower in rural than urban areas (5.1% vs. 6.1% of enrollees annually) and median OOP costs were nearly double ($195 vs. $98). The ACA reduced median OOP payments by $94 (p = .001) initially and $4 monthly (p = .038) in rural areas, and $63 (p < .001) in urban areas. The rural-urban gap in OOP payments dropped by $4 monthly (p = .007). The ACA also reduced rural-urban disparities in colonoscopy rates (disparity decrease of 0.005 (6%) monthly, p < .001). The rural-urban gap in colonoscopy rates declined 40% relative to the pre-ACA period by December 2012. ConclusionsThe ACA was associated with significant reductions in rural-urban disparities in colonoscopies in Maine, suggesting that OOP costs are an important barrier for rural residents. Further research is needed to determine whether increased uptake, particularly in rural areas, translated into better patient outcomes for colorectal cancer.

Disparities in colorectal cancer mortality for rural populations in the United States: Does screening matter?

IntroductionRural compared to urban populations in the US have increased colorectal cancer (CRC) incidence with known disparity in screening rates and mortality. We hypothesize that rural-urban disparities are different at a regional level. MethodsWe assessed screening rates according to the 2016 Behavioral Risk Factor Surveillance System guidelines using state and city-level data for county level estimates and correlating with county CRC mortality data from the National Cancer Institute. We used multivariable modeling to examine associations between rurality, screening rates, and mortality. ResultsHighest screening rate states had the smallest urban-rural disparities; lowest screening rate states had the largest disparities. Percent screened and urban-rural classification correlated significantly with mortality. Rural counties experienced ∼5 more deaths per 100,000 population even controlling for screening rates. ConclusionsNational urban-rural disparities in CRC screening mask greater state/regional disparities, not fully explaining the urban-rural mortality gap. Other factors (i.e. access to care, treatment differences) must be considered.

Sa1022 – Racial Disparities in Colorectal Cancer Mortality: the Role of Endoscopy Wait-Time and Disease Stage

Sa1022 – Racial Disparities in Colorectal Cancer Mortality: the Role of Endoscopy Wait-Time and Disease Stage

Colorectal Cancer Mortality Disparities in Cubans and Non-Cubans in the Florida Adult Population

Colorectal Cancer Mortality Disparities in Cubans and Non-Cubans in the Florida Adult Population

Assessing disparities in colorectal cancer mortality by socioeconomic status using new tools: health disparities calculator and socioeconomic quintiles

PurposeColorectal cancer mortality rates dropped by half in the past three decades, but these gains were accompanied by striking differences in colorectal cancer mortality by socioeconomic status (SES). Our research objective is to examine disparities in colorectal cancer mortality by SES, using a scientifically rigorous and reproducible approach with publicly available online tools, HD*Calc and NCI SES Quintiles.MethodsAll reported colorectal cancer deaths in the United States from 1980 to 2010 were categorized into NCI SES quintiles and assessed at the county level. Joinpoint was used to test for significant changes in trends. Absolute and relative concentration indices (CI) were computed with HD*Calc to graph change in disparity over time.ResultsDisparities by SES significantly declined until 1993–1995, and then increased until 2010, due to a mortality drop in populations living in high SES areas that exceeded the mortality drop in lower SES areas. HD*Calc results were consistent for both absolute and relative concentration indices. Inequality aversion parameter weights of 2, 4, 6 and 8 were compared to explore how much colorectal cancer mortality was concentrated in the poorest quintile compared to the richest quintile. Weights larger than 4 did not increase the slope of the disparities trend.ConclusionsThere is consistent evidence for a significant crossover in colorectal cancer disparity from 1980 to 2010. Trends in disparity can be accurately and readily summarized using the HD*Calc tool. The disparity trend, combined with published information on the timing of screening and treatment uptake, is concordant with the idea that introduction of medical screening and treatment leads to lower uptake in lower compared to higher SES populations and that differential uptake yields disparity in population mortality.

Abstract A40: Promoting colorectal cancer education: A partnership facilitated program evaluation examining generalizability across diverse populations

Abstract Background: Colorectal cancer (CRC) is the third leading cause of cancer-related deaths among men and women with over 96,000 new cases and 50,000 individuals expected to die from the disease in 2014. Cancer mortality rates, however, are higher among certain ethnic populations including Hispanics and American Indians/Alaska Natives (AI/AN). Through education and screening, CRC can be successfully detected early and treated before it progresses to advanced stages. The purpose of this study was to evaluate the effectiveness of a partnership-facilitated colorectal cancer education program across different ethnic populations in two U.S. regions. Pre/post design was used to measure changes in CRC knowledge as well as behavioral intentions to obtain screening and share CRC information obtained with others. Methods: The National Cancer Institute's National Outreach Network (NON) Community Health Educators (CHE) at New Mexico State University (NMSU) and at the Fred Hutchinson Cancer Research Center (FHCRC), a Comprehensive Partnership to Advance Health Equity (CPACHE) program, collaborated to develop an assessment tool that would evaluate the Inflatable Colon (IC) as a CRC educational tool across diverse ethnic populations. Instrument: NON CHE developed a pre/post-test assessment questionnaire based on literature reviews; questions asked about CRC knowledge, intention to obtain screening, and intention to disseminate CRC information. Procedure: In New Mexico, individuals at an educational institution were recruited to participate in this study, whereas participants in Eastern Washington were recruited at community health events. All study participants received the pre-test prior to touring the IC and the post-test after completing the IC tour. Results: A total of 1,286 individuals from Southern New Mexico and Eastern Washington participated in this study, 60% were males. We conducted a repeated measures analysis of covariance, including study site, age, education, insurance, regular doctor, and history of CRC as covariates. Analyses found a significant interaction by race/ethnicity and time, F (2, 1181) = 3.29, p = .04. After adjusting for covariates, there were significant differences in CRC knowledge across race/ethnicity, F (2, 1188) = 2.94, p = .05. Hispanic participants had a significantly greater change in knowledge relative to non-Hispanic whites (NHW). There was also a non-significant trend concerning AI/AN participants and NHW. Hispanic and AI/AN participants had greater change in intentions to obtain a CRC screening in the future relative to NHW. Subsequent post-hoc comparisons revealed that, relative to NHWs, Hispanics reported being more likely to intend to discuss CRC with their parents, p = .02, and grandparents, p = 0.003. AI/AN participants were also less likely to report to intend to discuss CRC with their parents, p = .04. Conclusion: This study examined the generalizability of a partnership-facilitated CRC educational program and assessment tool across different US populations and its effectiveness in increasing CRC knowledge as well as behavioral intention to obtain CRC screening and disseminate CRC information. This study suggests that the IC is an effective educational tool for increasing cancer knowledge and behavioral intentions among diverse ethnic populations. Complementing the IC intervention with access to free CRC screening, such as the FOBT kits, has the potential to address the CRC mortality disparities through the promotion of screening among certain ethnic populations and among those at a higher risk for CRC. Citation Format: Janeth I. Sanchez, Katherine Briant, Yamile Molina, Noah Espinoza, Nathan Marchello, Rebecca Palacios, Beti Thompson, Mary O'Connell. Promoting colorectal cancer education: A partnership facilitated program evaluation examining generalizability across diverse populations. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A40.

Beyond Adherence: Health Care Disparities and the Struggle to Get Screened for Colon Cancer.

Dominant health care professional discourses on cancer take for granted high levels of individual responsibility in cancer prevention, especially in expectations about preventive screening. At the same time, adhering to screening guidelines can be difficult for lower income and under-insured individuals. Colorectal cancer (CRC) is a prime example. Since the advent of CRC screening, disparities in CRC mortality have widened along lines of income, insurance, and race in the United States. We used a community-engaged research method, Photovoice, to examine how people from medically under-served areas experienced and gave meaning to CRC screening. In our analysis, we first discuss ways in which participants recounted screening as a struggle. Second, we highlight a category that participants suggested was key to successful screening: social connections. Finally, we identify screening as an emotionally laden process that is underpinned by feelings of uncertainty, guilt, fear, and relief. We discuss the importance of these findings to research and practice.

Socioeconomic Disparities in Colorectal Cancer Mortality in the United States, 1990–2007

United States colorectal cancer mortality rates have declined; however, disparities by socioeconomic status and race/ethnicity persist. The objective of this study was to describe the temporal association between colorectal cancer mortality and socioeconomic status by sex and race/ethnicity. Cancer mortality rates in the United States from 1990 to 2007, which were generated by the National Center for Health Statistics, and county-level socioeconomic status, which was estimated as the proportion of county residents living below the national poverty line based on 1990 US Census Bureau data, were obtained from the Surveillance, Epidemiology, and End Results program. The Kunst-Mackenbach relative index of inequality, which considers data across all poverty levels when comparing risks in the poorest (≥ 20%) and richest counties (<10%), was calculated as the measure of association. The study found that colorectal cancer mortality rates were significantly lower in the poorest counties than the richest counties during 1990-1992 among non-Hispanic whites, non-Hispanic black women and non-Hispanic API men. Over time though the tendency was for the poorest counties to have higher mortality rates. By 2003-2007 colorectal cancer mortality rates were significantly higher in the poorest than the richest counties among all sex-race/ethnicity groups. This disparity was most noticeable and appeared to be increasing most among Hispanic men. This suggests that socioeconomic disparities in colorectal cancer mortality were apparent after stratifying by sex and race/ethnicity and reversed over time. Further studies into the causes of these disparities would provide a basis for targeted cancer control interventions and allocation of public health resources.

Geographical variation and factors associated with colorectal cancer mortality in a universal health care system.

To investigate the geographical variation and small geographical area level factors associated with colorectal cancer (CRC) mortality. Information regarding CRC mortality was obtained from the population-based Manitoba Cancer Registry, population counts were obtained from Manitoba's universal health care plan Registry and characteristics of the area of residence were obtained from the 2001 Canadian census. Bayesian spatial Poisson mixed models were used to evaluate the geographical variation of CRC mortality and Poisson regression models for determining associations with CRC mortality. Time trends of CRC mortality according to income group were plotted using joinpoint regression. The southeast (mortality rate ratio [MRR] 1.31 [95% CI 1.12 to 1.54) and southcentral (MRR 1.62 [95% CI 1.35 to 1.92]) regions of Manitoba had higher CRC mortality rates than suburban Winnipeg (Manitoba's capital city). Between 1985 and 1996, CRC mortality did not vary according to household income; however, between 1997 and 2009, individuals residing in the highest-income areas were less likely to die from CRC (MRR 0.77 [95% CI 0.65 to 0.89]). Divergence in CRC mortality among individuals residing in different income areas increased over time, with rising CRC mortality observed in the lowest income areas and declining CRC mortality observed in the higher income areas. Individuals residing in lower income neighbourhoods experienced rising CRC mortality despite residing in a jurisdiction with universal health care and should receive increased efforts to reduce CRC mortality. These findings should be of particular interest to the provincial CRC screening programs, which may be able to reduce the disparities in CRC mortality by reducing the disparities in CRC screening participation.

Factors affecting African American men's use of online colorectal cancer education.

Colorectal cancer (CRC) incidence rates have decreased due to the increased use of CRC screenings that permit the detection and removal of polyps. However, CRC is still the second most common cause of cancer death among men ages 40 to 79 years; incidence and mortality rates for CRC are higher among African American (AA) men than among white men and AA women. CRC screening rates for AA men are comparable to their counterparts of other racial groups, but adherence to the screening guidelines is less, contributing to disparities in CRC mortality. Internet use is widespread and could be a channel to reach and disseminate health information to AA men; however, there are disparities in Internet use, and limited literature exists on how to best address this divide. This pilot project sought to understand African American male attitudes on colorectal cancer screening (CRCS), receipt of CRCS information, and the best strategy to provide African American men online CRCS education. Three focus groups and a feasibility trial were completed with African American men, ages of 45 to 75. Data suggest that disseminating information online is not a very effective way to reach older African American men with limited education. Although we do not recommend using websites among this population, email was more effective in getting participants to the website even though participants expressed a preference for phone messages. Recommendations for future research are provided.

Molecular Staging of Node Negative Patients with Colorectal Cancer

Metastatic disease is the principle cause of death from colorectal cancer. In that context, the most significant indicator of overall survival and therapeutic response to adjuvant chemotherapy is the presence of metastatic tumor cells in regional lymph nodes. Although histopathologic analysis of lymph nodes is central to all colorectal cancer staging paradigms, its prognostic and predictive value is limited. Indeed, about 30% of patients with histopathology-negative lymph nodes (pN0) die from metastatic disease, reflected by microscopic lymph node metastases that are overlooked by standard techniques. These unrecognized tumor cells are especially important when considering racial disparities in outcomes in colorectal cancer patients, where blacks with lymph node-negative disease have the largest discrepancies in outcomes, with more than 40% excess mortality compared to Caucasian patients. However, the significance of tumor cells in regional lymph nodes remains uncertain, and approximately 50% of colorectal cancer patients with nodal metastases detected by histopathology remain free of recurrent disease. Accurate identification of occult metastases in regional lymph nodes, and defining their value as prognostic markers of recurrence risk and predictive markers of response to adjuvant chemotherapy remains one challenge in the management of colorectal cancer patients. Guanylyl cyclase C (GUCY2C), a receptor which is expressed primarily in intestinal cells normally, but is universally over-expressed by colorectal cancer cells, has been validated to detect prognostically significant occult metastases using quantitative RT-PCR (RT-qPCR). Biomarker validation was achieved through a prospective, multicenter, blinded clinical trial. In that trial, occult tumor burden estimated across all regional lymph nodes by GUCY2C RT-qPCR predicted clinical outcomes, identifying node-negative patients with a low (near zero) risk, and those with >80% risk, of developing disease recurrence. Moreover, there was disproportionately higher occult tumor burden in black, compared to white, patients which contributes to racial disparities in outcomes in colorectal cancer. The diagnostic paradigm quantifying occult tumor burden using GUCY2C qRT-PCR is positioned to reduce racial disparities in colorectal cancer mortality.

Fundamental Causes of Colorectal Cancer Mortality in the United States: Understanding the Importance of Socioeconomic Status in Creating Inequality in Mortality

We used the fundamental cause hypothesis as a framework for understanding the creation of health disparities in colorectal cancer mortality in the United States from 1968 to 2005. We used negative binomial regression to analyze trends in county-level gender-, race-, and age-adjusted colorectal cancer mortality rates among individuals aged 35 years or older. Prior to 1980, there was a stable gradient in colorectal cancer mortality, with people living in counties of higher socioeconomic status (SES) being at greater risk than people living in lower SES counties. Beginning in 1980, this gradient began to narrow and then reversed as people living in higher SES counties experienced greater reductions in colorectal cancer mortality than those in lower SES counties. Our findings support the fundamental cause hypothesis: once knowledge about prevention and treatment of colorectal cancer became available, social and economic resources became increasingly important in influencing mortality rates.

Abstract A93: Contextualizing early detection: Lessons from lay definitions of colorectal cancer early detection.

Abstract Purpose of study: Practitioners and researchers often promote “early detection” as a key message in colorectal cancer (CRC) screening programs and as a strategy to reduce disparities in CRC mortality. To better understand the experience of CRC for individuals who face substantial health and income inequalities, this qualitatively research examines the meanings and understandings of “early detection” that may be overlooked by quantitative approaches. This study suggests that early detection messages are contextualized and interpreted within lived experiences. Procedures: Six focus groups and 21 open-ended interviews were conducted during 2006 and 2007 to examine understandings of CRC screening and detection. The study took place at an urban community health center in a U.S. Midwestern city and focused on adults age 45 years and older. Most participants were female, African American, unemployed, and had no more than a high school education. Nearly half were without any type of health insurance. Transcripts were analyzed by two coders, who used an inductive data analysis approach. Summary of Data: Four key findings were identified throughout the transcripts. First, participants made sense of CRC through comparisons to a range of diseases experienced in their families and communities and seen in public health campaigns. Second, they utilized statements about early and late detection of cancer to make sense of past personal and family experiences with cancer. Most participants had experienced multiple deaths of family and friends to cancer and were drawing on early detection messages to grapple with their sadness, guilt, and blame over why loved ones had died. Third, CRC screening and detection were viewed within the context of possible treatments and treatment outcomes. Ideas about treatment accessibility and effectiveness heavily influenced participants' approaches to accessing screenings. Finally, rather than an avoidance of health-seeking behavior, participants demonstrated and discussed their persistence in attempting to achieve diagnoses and treatment with limited resources. Conclusion: The study findings suggest that frequently invoked constructs in preventive health, such as early detection and the treatability of cancer in its earliest stages, take on much more complex meanings than researchers, practitioners, and clinicians may expect. Examining these meanings offers a starting point for understanding and redressing CRC disparities in populations that have experienced significant inequities in access to quality healthcare, which have sometimes endured over generations. Researchers should consider social contexts and deeper meanings when developing communications that emphasize early detection and when using measures that ask individuals about early detection beliefs and behaviors. Citation Format: Jean M. Hunleth, Nancy Mueller, Aimee James. Contextualizing early detection: Lessons from lay definitions of colorectal cancer early detection. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A93.

Bridging Behavior and Biology to Reduce Socioeconomic Disparities in Colorectal Cancer Risk

During the last quarter of the 20th century, the incidence of colorectal cancer in the United States declined by 22%. Half of this decline has been attributed to changes in health behaviors, such as red meat consumption and physical activity, and the other half has been ascribed to increased screening with fecal occult blood testing, sigmoidoscopy, and colonoscopy (1). The declining incidence of colorectal cancer accelerated from 1999 to 2008 with average annual reductions of 2%–3% for both men and women (2), representing a shared accomplishment of public health and health care. These improvements, however, have been disproportionately concentrated among more educated and affluent Americans. In 2000, rates of obesity were higher and rates of colorectal cancer screening were substantially lower among adults with less education, as reported in the National Health Interview Survey (3). As a result, even though the overall incidence of colorectal cancer has declined in recent decades, socioeconomic disparities in colorectal cancer incidence remain substantial (4). Moreover, disparities in colorectal cancer mortality by education and race have actually increased since 1993 and thus represent a growing concern (5).

Fundamental Causes of Colorectal Cancer Mortality: The Implications of Informational Diffusion

Colorectal cancer is a major cause of mortality in the United States, with 52,857 deaths estimated in 2012. To explore further the social inequalities in colorectal cancer mortality, we used fundamental cause theory to consider the role of societal diffusion of information and socioeconomic status. We used the number of deaths from colorectal cancer in U.S. counties between 1968 and 2008. Through geographical mapping, we examined disparities in colorectal cancer mortality as a function of socioeconomic status and the rate of diffusion of information. In addition to providing year-specific trends in colorectal cancer mortality rates, we analyzed these data using negative binomial regression. The impact of socioeconomic status (SES) on colorectal cancer mortality is substantial, and its protective impact increases over time. Equally important is the impact of informational diffusion on colorectal cancer mortality over time. However, while the impact of SES remains significant when concurrently considering the role of diffusion of information, the propensity for faster diffusion moderates its effect on colorectal cancer mortality. The faster diffusion of information reduces both colorectal cancer mortality and inequalities in colorectal cancer mortality, although it was not sufficient to eliminate SES inequalities. These findings have important long-term implications for policymakers looking to reduce social inequalities in colorectal cancer mortality and other, related, preventable diseases.