Late-stage Colorectal Cancer Diagnosis Research Articles

Effect of a Theory-Based Narrative Video on Colorectal Cancer Screening Intention, Knowledge, and Psychosocial Variables Among a Predominantly Hispanic Population.

Colorectal cancer (CRC) remains the third leading cause of cancer death in the USA. Latinx adults are overrepresented in late-stage CRC diagnosis as CRC screening utilization remains low among Latinx-identifying individuals. This study aims to evaluate the effect of a theory-based narrative video following a culturally appropriate storyline on CRC screening intention, knowledge, and psychosocial variables along the U.S.-Mexico border. We designed and analyzed a non-randomized pre-posttest evaluation of a narrative, culturally tailored video embedded within a community program. The study is set in the U.S.-Mexico border community. Outreach provided a link or QR code to access the survey. In all, 458 participants started the survey, and 304 completed the survey. Participants were recruited through flyers distributed throughout various community events by the program's community health workers and via social media. The intervention evaluated changes in participant's knowledge, perceived barriers, perceived susceptibility, self-efficacy, and perceived benefits and intention to screen. Participants were a mean age of 39 and identified mainly as female (72.7%) and Hispanic/Latinx (88.49%). After viewing the narrative video, participants had significantly improved perceived susceptibility, self-efficacy, and benefits, while perceived barriers and sense of fatalism significantly decreased. Paradoxically, this was associated with a significant decrease in knowledge scores. Results from this intervention suggest that a theory-based narrative video following a culturally appropriate storyline effectively improves psychosocial variables and intention to carry out CRC screening in a predominantly Hispanic border population.

Machine Learning as a Tool for Early Detection: A Focus on Late-Stage Colorectal Cancer across Socioeconomic Spectrums

Purpose: To assess the efficacy of various machine learning (ML) algorithms in predicting late-stage colorectal cancer (CRC) diagnoses against the backdrop of socio-economic and regional healthcare disparities. Methods: An innovative theoretical framework was developed to integrate individual- and census tract-level social determinants of health (SDOH) with sociodemographic factors. A comparative analysis of the ML models was conducted using key performance metrics such as AUC-ROC to evaluate their predictive accuracy. Spatio-temporal analysis was used to identify disparities in late-stage CRC diagnosis probabilities. Results: Gradient boosting emerged as the superior model, with the top predictors for late-stage CRC diagnosis being anatomic site, year of diagnosis, age, proximity to superfund sites, and primary payer. Spatio-temporal clusters highlighted geographic areas with a statistically significant high probability of late-stage diagnoses, emphasizing the need for targeted healthcare interventions. Conclusions: This research underlines the potential of ML in enhancing the prognostic predictions in oncology, particularly in CRC. The gradient boosting model, with its robust performance, holds promise for deployment in healthcare systems to aid early detection and formulate localized cancer prevention strategies. The study’s methodology demonstrates a significant step toward utilizing AI in public health to mitigate disparities and improve cancer care outcomes.

Abstract A036: Associations between area-level social determinants and late-stage diagnosis of colorectal cancers

Abstract Introduction Systemic policies and disinvestment in some communities have created deep inequities in the social and economic conditions in which some communities live. There are documented disparities in the detection and diagnosis of colorectal cancer (CRC) and stage-appropriate treatment, which drives cancer outcomes, such as survival. Using the Andersen-Aday model of access to healthcare, prior researchers have identified person-specific factors associated with late-stage diagnosis. In this study, we investigated whether area-level measures that may related to CRC screening barriers were associated with late-stage CRC diagnoses. Methods We used data from the Surveillance, Epidemiology, and End Results (SEER) and selected cases of adult (18+ years) colorectal cancer diagnosed from 2006-2013 (most recent years available; n=234,232). This data was linked to Medicaid enrollment information. We merged census-tract level data from the American Community Survey (2010 midpoint) capturing transportation access (% utilizing public transit for commuting), housing quality and cost (more than 1 person occupying per room and rent > 30% of income), language proficiency (% speaking English less than well), receipt of SNAP benefits, as well as poverty rate and educational attainment (% in tract attaining a high school education or less). We tested these variables as separate multivariable logistic regression models using late-stage CRC diagnosis (AJCC Stage IV vs Stages 0-III) as the dependent variable to test the association between each area factor, controlling for age, sex, race, marital status, and others. Results In all, 24% of CRC cases were diagnosed in Stage IV. High poverty areas (20+% poverty compared vs. <5% poverty OR = 1.10, CI: 1.07-1.15) and areas with lower educational attainment (lowest educational quartile vs. highest OR = 1.11 CI: 1.07-1.15) are associated with higher odds of Stage IV CRC diagnosis. Areas utilizing more public transit (most use quartile vs. least use quartile, OR = 1.04, CI: 1.01-1.07) and more SNAP benefits (most use vs. least use quartile, OR = 1.13, CI = 1.09-1.17), are also associated with higher odds of Stage IV diagnosis. High occupancy housing areas were associated with higher odds of Stage IV CRC diagnosis (highest occupancy quartile vs. lowest OR = 1.04, CI = 1.01-1.07), while affordability of rent was not. Area-level English proficiency was also not associated with later diagnosis. Conclusions Area-level social determinants are important factors in CRC detection and control. Early diagnosis is a key factor in better survival after CRC. It is important to understand specifically which area-level factors are most important in early detection to inform interventions to reduce disparities in late-stage CRC diagnosis. Citation Format: Manami Bhattacharya, Lindsey Enewold, Amy Davidoff. Associations between area-level social determinants and late-stage diagnosis of colorectal cancers [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A036.

Time to Colonoscopy After Abnormal Stool-Based Screening and Risk for Colorectal Cancer Incidence and Mortality

The optimal time interval for diagnostic colonoscopy completion after an abnormal stool-based colorectal cancer (CRC) screening test is uncertain. We examined the association between time to colonoscopy and CRC outcomes among individuals who underwent diagnostic colonoscopy after abnormal stool-based screening. We performed a retrospective cohort study of veterans age 50 to 75 years with an abnormal fecal occult blood test (FOBT) or fecal immunochemical test (FIT) between 1999 and 2010. We used multivariable Cox proportional hazards to generate CRC-specific incidence and mortality hazard ratios (HRs) and 95% confidence intervals (CI) for 3-month colonoscopy intervals, with 1 to 3 months as the reference group. Association of time to colonoscopy with late-stage CRC diagnosis was also examined. Our cohort included 204,733 patients. Mean age was 61 years (SD 6.9). Compared with patients who received a colonoscopy at 1 to 3 months, there was an increased CRC risk for patients who received a colonoscopy at 13 to 15 months (HR 1.13; 95% CI 1.00-1.27), 16 to 18 months (HR 1.25; 95% CI 1.10-1.43), 19 to 21 months (HR 1.28; 95% CI: 1.11-1.48), and 22 to 24 months (HR 1.26; 95% CI 1.07-1.47). Compared with patients who received a colonoscopy at 1 to 3 months, mortality risk was higher in groups who received a colonoscopy at 19 to 21 months (HR 1.52; 95% CI 1.51-1.99) and 22 to 24 months (HR 1.39; 95% CI 1.03-1.88). Odds for late-stage CRC increased at 16 months. Increased time to colonoscopy is associated with higher risk of CRC incidence, death, and late-stage CRC after abnormal FIT/FOBT. Interventions to improve CRC outcomes should emphasize diagnostic follow-up within 1 year of an abnormal FIT/FOBT result.

Abstract A129: Racial/ethnic disparities in patient experiences with health care and the association with earlier stage at colorectal cancer diagnosis: Findings from the SEER-CAHPS data

Abstract Background: Racial/ethnic minorities are more likely to be diagnosed at a later stage of colorectal cancer (CRC). Disparities in late-stage CRC diagnosis are partly attributed to socioeconomic inequalities, poor access to early detection screening and poor access to timely, high-quality diagnostic care. Although these findings are useful for identifying subgroups at high-risk for late-stage CRC diagnosis, few studies have focused on potentially modifiable factors at the patient, healthcare system and provider-level. Therefore, our objective was to identify whether racial/ethnic differences in patient experiences with healthcare are associated with stage at CRC diagnosis. Methods: We used the NCI Surveillance, Epidemiology and End Results (SEER) registry data linked with patient surveys from the Consumer Assessment of Healthcare Providers and Systems (CAHPS). CAHPS surveys are administered to a random sample of Medicare beneficiaries on fee-for-service or Medicare advantage health plans by the Centers for Medicaid and Medicare Services. We conducted a retrospective cohort analysis of patients >64 years old diagnosed with colorectal cancer from 1997-2011 who completed a CAHPS survey prior to the date of their CRC diagnosis. We examined the composite measures from CAHPS survey to assess patient experiences with care which we categorized into three domains: 1) patient-centeredness, 2) timeliness, and 3) realized access. Race/ethnicity was assessed using a self-reported measure from the CAHPS survey. We used multivariable linear regression to examine racial/ethnic differences in patient experiences with care for each domain controlling for sociodemographic and health characteristics. We ran a multivariable logistic regression model to determine the association between patient experiences with care and earlier stage (stage 0 and 1) at diagnosis. Results: Of the 9,211 patients, 79.7% were non-Hispanic white, 7.7% black, 7.4% Hispanic, and 5.2% Asian. After controlling for potential confounders, for the timeliness of care domain, Asian patients had significantly lower adjusted mean scores for getting care quickly (B=-6.65, 95% CI: -9.44, -3.87) compared to white patients. While for the realized access domain, Asian and non-Hispanic black patients had significantly lower adjusted mean scores for getting needed prescription drugs, B=-5.78 (95% CI: -8.51, -3.05) and B=-3.18 (95% CI: -5.50, -0.87), respectively. More importantly, we found that black patients who reported a 5-unit increase in rating of their experiences with getting needed care quickly (OR: 1.06, 95% CI: 1.01-1.10) had higher odds of being diagnosed at an earlier stage of colorectal cancer. Conclusion: There are racial/ethnic disparities in patient experiences with timeliness of and realized access to care preceding a diagnosis of colorectal cancer. Our study suggests that among black patients, poor experiences with timeliness of care may be associated with later stage at diagnosis. Citation Format: Carol Y Ochoa, Gabriela Toledo, Albert J Farias. Racial/ethnic disparities in patient experiences with health care and the association with earlier stage at colorectal cancer diagnosis: Findings from the SEER-CAHPS data [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 A129.

Associations between area-level deprivation, rural residence, physician density, screening policy and late-stage colorectal cancer in Canada

BackgroundImportant social disparities in colorectal screening exist in Canada. Few studies have assessed disparities further along the cancer control continuum. Here we assess the associations between social and material deprivation, physician density, rural residence, and the absence of provincial mail-based screening programs and colorectal cancer (CRC) stage at diagnosis. MethodsColorectal cancer cases and stage data (“local or regional” if stage 0, I, or II, “late” if stage III or IV) were obtained through the Canadian Cancer Registry (2011–2015, N = 54,745). Cases were linked to 2006 Canadian Census Dissemination Area-level data on rural/urban status, exposure to a provincial mail-based screening program, and social and material deprivation (Pampalon Index quintile groups); and to Scott’s Medical Database 2011 physician density data (<7 vs. ≥ 7/10,000). Age, sex, and predictor-adjusted Generalized estimating equation (GEE) Poisson models were used to determine independent associations between predictors and late-stage at diagnosis. ResultsHalf of CRC cases are diagnosed at stage III or IV (51 %), with younger age groups experiencing higher late-stage prevalence (57 % among those aged 18–49). The covariate-adjusted late-stage prevalence was 2-percentage points higher in most materially- and socially-deprived areas (95 % CI: 1 %, 4 %, in both, respectively) and in provinces with no mail-based screening programs (95 % CI: 1 %, 2 %). No significant differences were observed according to rural residence or physician density. ConclusionsSocial disparities in late-stage CRC diagnosis are modest. Continued surveillance of these disparities may be warranted as provinces continue to promote early cancer detection through screening, and stage distributions may change overtime.

Investigating the Impact of Geographic Location on Colorectal Cancer Stage at Diagnosis: A National Study of the SEER Cancer Registry.

Early detection of colorectal cancer (CRC) is associated with decreased mortality and potential avoidance of chemotherapy. CRC screening rates are lower in rural communities and patient outcomes are poorer. This study examines the extent to which United States' rural residents present at a more advanced stage of CRC compared to nonrural residents. Using the 2010-2014 Surveillance, Epidemiology and End Results Incidence data, 132,277 patients with CRC were stratified using their county of residence and urban influence codes into 5 categories (metro, adjacent micropolitan, nonadjacent micropolitan, small rural, and remote small rural). Logistic regression was used to investigate the relationship between late stage at diagnosis and county-level characteristics including level of rurality, persistent poverty, low education and low employment, and patient characteristics. In the adjusted analysis the rate of stage 4 CRC at diagnosis differed across geographic classification, with patients living in remote small rural counties having the highest rate of stage 4 disease (range: 19.2% in nonadjacent micropolitan counties to 22.7% in remote small rural counties). Other factors, such as patient characteristics, insurance status, and regional practice variation were also significantly associated with late-stage CRC diagnosis. Geographic residence is associated with the rate of stage 4 disease at presentation. Additional patient factors are associated with stage 4 CRC disease at diagnosis. Cancer outcomes are worse for rural patients, and late stage at diagnosis may partially account for this disparity. These differences have persisted over time and suggest areas for further research, patient engagement, and education.

Risk Factors for Diagnosis of Colorectal Cancer at a Late Stage: a Population-Based Study.

Late-stage colorectal cancer (CRC) is associated with significantly less effective treatment and poorer survival than early-stage colorectal cancer. Identify and assess patient characteristics, demographic factors, and lifestyle factors that are associated with late-stage colorectal cancer at diagnosis. We linked two longstanding statewide, population-based registry databases: the New Hampshire Colonoscopy Registry and the New Hampshire State Cancer Registry, to assess the associations between patient characteristics and late-stage CRC diagnoses. The State Cancer Registry provided information on cancer stage and the Colonoscopy Registry provided detailed information on patient characteristics and lifestyle factors, allowing these factors to be analyzed in relation to colorectal cancer stage. The risk of late-stage CRC diagnosis was highest among those diagnosed at a young age (< 50years old) (OR 1.81, 95% CI 1.27-2.58). Those with Medicaid were also at increased risk, particularly < 65years of age (OR 2.32, 95% CI 1.05-5.26). A family or personal history of polyps and/or CRC was associated with early stage at diagnosis (p = 0.014). Public health outreach and screening efforts should focused on patients at risk of late-stage CRC to encourage earlier diagnosis and prevention. Underserved patients have a lower rate of CRC screening and an increased risk of late-stage CRC, emphasizing the critical need to reach these populations. Further investigation of susceptibility characteristics and the effectiveness of non-invasive early screening techniques is warranted to address the late-stage CRC diagnoses in young individuals.

Using residential segregation to predict colorectal cancer stage at diagnosis: two different approaches

PurposeStudies have found a variety of evidence regarding the association between residential segregation measures and health outcomes in the United States. Some have focused on any individuals living in residentially segregated places, whereas others have examined whether persons of specific races or ethnicities living in places with high segregation of their own race or ethnicity have differential outcomes. This article compares and contrasts these two approaches in the study of predictors of late-stage colorectal cancer (CRC) diagnoses in a cross-national study. We argue that it is very important when interpreting results from studies like this to carefully consider the geographic scope of the analysis, which can significantly change the context and meaning of the results. MethodsWe use US Cancer Statistics Registry data from 40 states to identify late-stage diagnoses among over 500,000 CRC cases diagnosed during 2004–2009. We pool data over the states and estimate a multilevel model with person, county, and state levels and a random intercepts specification to ensure robust effect estimates. The isolation index of residential segregation is defined for racial and ethnic groups at the county level using Census 2000 data. The association between isolation indices and late-stage CRC diagnosis was measured by (1) anyone living in minority-segregated areas (place-centered approach) and by (2) individuals living in areas segregated by one's own racial or ethnic peers (person-centered approach). ResultsFindings from the place-centered approach suggest that living in a highly segregated African American community is associated with lower likelihood of late-stage CRC diagnosis, whereas the opposite is true for people living in highly segregated Asian communities, and living in highly segregated Hispanic communities has no significant association. Using the person-centered approach, we find that living in places segregated by one's racial or ethnic peers is associated with lower likelihood of late-stage CRC diagnosis. ConclusionsIn a model that covers a large geographic area across the nation, the place-centered approach is most likely picking up geographic disparities that may be deepened by targeted interventions in minority communities. By contrast, the person-centered approach provides a national average estimate suggesting that residential isolation may confer community cohesion or support that is associated with better CRC prevention.

How generalizable are the SEER registries to the cancer populations of the USA?

We determined whether the current SEER registries are representative of the nation's cancer cases or the socio-demographic characteristics. We used breast cancer (BC) and colorectal cancer (CRC) cases diagnosed 2004-2009 from the US Cancer Statistics (USCS) database. Cases were classified into groups residing in SEER coverage areas and the other areas. We compared difference between SEER and non-SEER areas in: age-race-specific proportions of late-stage BC or CRC, area demographics and socioeconomic factors, and data quality. For late-stage CRC diagnosis, SEER areas contained lower proportions of people with other race and higher proportions of Asian and Hispanic females aged <40, than non-SEER areas. For late-stage BC diagnosis, SEER and non-SEER estimates were comparable. SEER areas had lower percentages of whites and higher percentages of young people, were more urban, and had higher percentage of poor, lower educational attainment, and higher unemployment. SEER areas also tended to have a higher percentage of case completeness than non-SEER areas. Overall, SEER registries were not significantly different from non-SEER areas in terms of average age-race-specific proportions of late-stage BC or CRC, except for estimates of late-stage CRC for other race and young Asian and Hispanic women. Although case completeness was better in SEER areas than non-SEER areas, SEER areas had greater economic disadvantage and greater minority diversity among the population. This study demonstrated a need for caution in using SEER data and discussed advantages of using the more complete USCS database.

The Relationship between Neighborhood Immigrant Composition, Limited English Proficiency, and Late-Stage Colorectal Cancer Diagnosis in California

Despite the availability of effective early detection technologies, more than half (61%) of colorectal cancers in the United States and 55% in California are identified at an advanced stage. Data on colorectal cancer patients (N = 35,030) diagnosed from 2005 to 2007 were obtained from the California Cancer Registry. Multivariate analyses found a relationship among neighborhood concentration of recent immigrants, neighborhood rates of limited English proficiency, and late-stage colorectal cancer diagnosis. Hispanics living in neighborhoods with a greater percentage of recent immigrants (compared to the lowest percentage) had greater odds (OR 1.57, 95% CI 1.22, 2.02) of late-stage diagnosis whereas Hispanics living in neighborhoods with the highest percentage of limited English proficiency (compared to the lowest percentage) had lower odds (OR .71, 95% CI .51, .99) of late-stage diagnosis. These relationships were not observed for other ethnic groups. Results highlight the complex relationship among race/ethnicity, neighborhood characteristics, and colorectal cancer stage at diagnosis.

Abstract C90: Colorectal cancer among Hispanics in the U.S.: Nativity disparities in stage at diagnosis and survival

Abstract Introduction: Compared to non-Hispanic whites, Hispanics in the U.S. are significantly more likely to be diagnosed with late-stage colorectal cancer (CRC) and have a higher CRC-specific mortality hazard. While the low CRC screening rates among Hispanics (29%) are known to be lowest among foreign-born individuals (22%), few studies have examined CRC disparities by nativity. Here we examine differences in late-stage CRC diagnosis and survival among U.S.- and foreign-born Hispanics. Methods: We used data from the Surveillance, Epidemiology, and End Results (SEER) program. Cases were Hispanic men and women diagnosed with primary invasive CRC between 1988 and 2008. Nativity was based on place of birth and was categorized as U.S.- versus foreign-born. Missing nativity values were imputed using multiple imputation by logistic regression, a strategy with high sensitivity (91%) and specificity (90%) for detecting foreign-born status. Distant and regional tumors were classified as late-stage; local tumors were classified as early-stage. Multivariable logistic regression was used to assess the association between late-stage diagnosis and nativity after adjusting for demographic characteristics (age at diagnosis and gender) and anatomic subsite (proximal, distal, rectum, or other). Multivariable Cox regression was used to assess the association between CRC-specific survival and nativity after adjusting for demographic characteristics, tumor characteristics (stage at diagnosis and anatomic subsite), and receipt of cancer-directed therapy (surgery and radiation). Results: Fifty eight percent of cases of invasive CRC among Hispanics were diagnosed at a late stage and 63% of cases were among foreign-born individuals. Foreign-born Hispanics were significantly more likely than U.S.-born Hispanics to have a late-stage diagnosis after adjusting for demographic characteristics (adjusted odds ratio=1.08, p&amp;lt;0.001). However, the demographics-adjusted mortality hazard was similar among foreign- and U.S.-born Hispanics (adjusted hazard ratio [AHR]=0.99, p-value=0.790). After adjusting for tumor characteristics, foreign-born Hispanics had improved survival compared to their U.S.-born counterparts (AHR=0.94, p=0.005). Their survival advantage remained significant after adjusting for both tumor characteristics and cancer-directed therapy (AHR=0.92, p&amp;lt;0.001). Conclusions: The increased prevalence of late-stage diagnosis among foreign-born Hispanics is likely a reflection of their reduced screening rates relative to Hispanics born in the U.S. However, the increased risk of late-stage diagnosis did not result in an increased mortality hazard among foreign-born Hispanics. In fact, survival was better among foreign- versus U.S.-born Hispanics after adjusting for stage at diagnosis and receipt of cancer-directed therapy. Similar patterns have been found for cervix and overall cancer survival and may be attributed to changes in risk profiles associated with acculturation (e.g., higher rates of smoking, obesity, alcohol consumption, and poor nutrition). Additionally, U.S.-born Hispanics have a higher prevalence of chronic diseases (e.g., diabetes, obesity, heart disease) that may negatively affect cancer survival. Our results suggest that the overlap between race/ethnicity and nativity status should not be overlooked in cancer health disparities research. Citation Format: Jane R. Montealegre, Renke Zhou, E. Susan Amirian, Michael E. Scheurer. Colorectal cancer among Hispanics in the U.S.: Nativity disparities in stage at diagnosis and survival. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C90. doi:10.1158/1538-7755.DISP13-C90

Abstract B46: FIT FOR LIFE: Increasing prevention and early detection of colorectal cancer for the medically disenfranchised

Abstract Background: Racial/ethnic minorities, low-income individuals and recent immigrants shoulder a disproportionate burden of colorectal cancer (CRC) mortality. In Florida, Blacks and Hispanics remain at an increased risk of colorectal cancer (CRC) compared to non-Hispanic Whites (NHW). In the Miami metropolitan area, this disparity is most prominent within the ethnic enclaves of Little Haiti and Hialeah, comprised predominately of Haitian and Hispanic Americans, respectively These communities experience an increased rate of late-stage CRC diagnosis relative to the state as a whole, largely due to lack of access to, and utilization of, CRC screening. Fecal immunochemical testing (FIT) has proved successful in addressing screening barriers for other medically-underserved communities. The present study represents a novel method for FIT delivery and uptake, particularly for the medically disenfranchished. Community Health Workers (CHWs), indigenous to Little Haiti and Hialeah, identified unscreened individuals, educated them about how to appropriately use FIT, and then provided them a postage-paid envelope to return completed tests to a laboratory for processing. Here we report preliminary acceptability and feasibility data for this approach. Methods: The FIT for Life screening program was available to all persons residing in Little Haiti and Hialeah 50 and 75 years old, who were unscreened or underscreened according to US Preventive Task Force recommendations, and considered average risk for CRC based on a brief screener. Our team worked closely with community partners to identify the CHWs, who ultimately were responsible for participant recruitment and intervention delivery. Following FIT return, a research assistant contacted participants to ask a series of questions in their language of preference about their perceived acceptability of FIT as a modality for CRC prevention. Any participant, identified as FIT positive was navigated to timely colonoscopy Results: To date, 221 participants (112 Hispanic, 109 Haitian) have been consented, received education on CRC screening, and were given the FIT kits. 92 Hispanics (82.1%) and 97 Haitians (88.9%) returned the FIT kits for processing. The test positive rate was 2.2% for Hispanics and 3.1% for Haitians. The mean quantity of blood in stool for positive tests was 896 ng/mL for Hispanics and 950 ng/mL for Haitians. The mean quantity of blood in stool for negative tests was 5.2 ng/mL for Hispanics and 4.8 ng/mL for Haitians. On follow-up clinical care, one Haitian participant was found to have an advanced stage CRC and a second did not want to undergo colonoscopy. Based on acceptability surveys, 100% of Hispanics and 90% of Haitians responded that they would use FIT again if offered for further screening; the same proportions would recommend the FIT with CHW method to friends and family members. Interestingly, 90.2% of Hispanics and only 5.0% of Haitians felt confident that FIT works as well as a CRC screening test that would be administered by a physician or nurse. Conclusion: The pairing of CHWs with CRC screening by FIT appears to be an effective approach to disease prevention that is highly acceptable to study participants. Further examination of whether this method is needed. We have begun collaborating with Federally Qualified Health Centers (FQHC) in Little Haiti and Hialeah to explore the sustainability of this approach and to ensure that participants are linked to a medical home for ongoing cancer prevention. Citation Format: Daniel Sussman, Monica Oriol, Martha Gonzalez, Heisy Asusta, Jose Ruiz, Dinah Trevil, Dorothy Parker, Erin Kobetz. FIT FOR LIFE: Increasing prevention and early detection of colorectal cancer for the medically disenfranchised. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B46. doi:10.1158/1538-7755.DISP13-B46

Approaches for classifying the indications for colonoscopy using detailed clinical data

BackgroundAccurate indication classification is critical for obtaining unbiased estimates of colonoscopy effectiveness and quality improvement efforts, but there is a dearth of published systematic classification approaches. The objective of this study was to evaluate the effects of data-source and adjudication on indication classification and on estimates of the effectiveness of screening colonoscopy on late-stage colorectal cancer diagnosis risk.MethodsThis was an observational study in members of four U.S. health plans. Eligible persons (n = 1039) were age 55–85 and had been enrolled for 5 years or longer in their health plans during 2006–2008. Patients were selected based on late-stage colorectal cancer diagnosis in a case–control design; each case patient was matched to 1–2 controls by study site, age, sex, and health plan enrollment duration. Reasons for colonoscopies received in the 10-year period before the reference date were collected from three medical records sources (progress notes; referral notes; procedure reports) and categorized using an algorithm, with committee adjudication of some tests. We evaluated indication classification concordance before and after adjudication and used logistic regressions with the Wald Chi-square test to compare estimates of the effects of screening colonoscopy on late-stage colorectal cancer diagnosis risk for each of our data sources to the adjudicated indication.ResultsClassification agreement between each data-source and adjudication was 78.8-94.0% (weighted kappa = 0.53-0.72); the highest agreement (weighted kappa = 0.86-0.88) was when information from all data sources was considered together. The choice of data-source influenced the association between screening colonoscopy and late-stage colorectal cancer diagnosis; estimates based on progress notes were closest to those based on the adjudicated indication (% difference in regression coefficients = 2.4%, p-value = 0.98), as compared to estimates from only referral notes (% difference in coefficients = 34.9%, p-value = 0.12) or procedure reports (% difference in coefficients = 27.4%, p-value = 0.23).ConclusionThere was no single gold-standard source of information in medical records. The estimates of colonoscopy effectiveness from progress notes alone were the closest to estimates using adjudicated indications. Thus, the details in the medical records are necessary for accurate indication classification.

Primary Care Utilization and Colorectal Cancer Incidence and Mortality Among Medicare Beneficiaries

Utilization of primary care may decrease colorectal cancer (CRC) incidence and death through greater receipt of CRC screening tests. To examine the association of primary care utilization with CRC incidence, CRC deaths, and all-cause mortality. Population-based, case-control study. Medicare program. Persons aged 67 to 85 years diagnosed with CRC between 1994 and 2005 in U.S. Surveillance, Epidemiology, and End Results (SEER) regions matched with control patients (n = 205,804 for CRC incidence, 54,160 for CRC mortality, and 121,070 for all-cause mortality). Primary care visits in the 4- to 27-month period before CRC diagnosis, CRC incidence, CRC mortality, and all-cause mortality. Compared with persons having 0 or 1 primary care visit, persons with 5 to 10 visits had lower CRC incidence (adjusted odds ratio [OR], 0.94 [95% CI, 0.91 to 0.96]) and mortality (adjusted OR, 0.78 [CI, 0.75 to 0.82]) and lower all-cause mortality (adjusted OR, 0.79 [CI, 0.76 to 0.82]). Associations were stronger in patients with late-stage CRC diagnosis, distal lesions, and diagnosis in more recent years when there was greater Medicare screening coverage. Ever receipt of CRC screening and polypectomy mediated the association of primary care utilization with CRC incidence. This study used administrative data, which made it difficult to identify potential confounders and prevented examination of the content of primary care visits. Medicare beneficiaries with higher utilization of primary care have lower CRC incidence and mortality and lower overall mortality. Increasing and promoting access to primary care in the United States for Medicare beneficiaries may help decrease the national burden of CRC. American Cancer Society.

Spatial Access to Health Care Services and Disparities in Colorectal Cancer Stage at Diagnosis in Texas*

Early diagnosis of colorectal cancer (CRC) is important for improving the survival rate of the disease. Disparities in CRC diagnosis among different population groups have persisted in the United States. This study examines whether spatial access to medical services contributes to disparities of late-stage diagnosis of CRC in Texas. Analysis results suggest that there are significant disparities in late-stage CRC diagnosis by race/ethnicity, socioeconomic status, and geographic location in Texas. It is concluded that spatial access to primary care is associated with CRC stage at diagnosis, but not with racial/ethnic and socioeconomic disparities.

Changes in early- and late-stage colorectal cancer incidence during the era of screening: 1976-2009.

1522 Background: Ideally, screening detects cancer at a more curable stage, and as a result decreases the incidence of subsequent diagnosis at a late stage. Whereas breast cancer screening is suggested to have led to a substantial increase in the number of early-stage cancers diagnosed in the United States with only marginal reductions in the number of late stage cancers, the impact of colorectal cancer screening on cancer incidence is unknown. Methods: Colorectal cancer incidence data spanning over three decades, 1976—2009, were collected from the Surveillance, Epidemiology, and End Result (SEER) database. Screening utilization data spanning 1986—2010 were collected from the National Health Survey (NHS) progress reports. We examined trends in the incidence of early-stage (in situ, local) and late-stage (regional, distant) colorectal cancer among adults 50 years or older. Results: Over the past three decades, the incidence of late-stage colorectal cancer decreased significantly, from 118 to 74 cases per 100,000 people—a 37% decrease. The incidence of early-stage colorectal cancer also decreased, from 77 to 67 cases per 100,000 people. There was also an associated increase in the utilization rates of screening colonoscopy. From 1987 to 2010—the years for which NHS data were available—the percentage of adults 50 and older who received screening colonoscopy rose from 27% to 63%. After adjusting for trends in cancer incidence in non-screened populations, we estimated that colorectal screening was associated with a reduction of approximately 550,000 cases of colorectal cancer over the past three decades in the United States. Using the most conservative assumption of constant cancer incidence during the past three decades, 235,000 cases of colorectal cancer were prevented. Conclusions: There has been a significant decline in both early and late stage colorectal cancer diagnoses, during a time of increasing rates of increased screening.

Mo1566 Screening Colonoscopy and Risk of Incident Late-Stage Colorectal Cancer Diagnosis in Average-Risk Adults: a Nested Case-Control Study

The effectiveness of screening colonoscopy in average-risk adults is uncertain, particularly for right colon cancers. We examined the association between screening colonoscopy and the risk of diagnosis with incident late-stage colorectal cancer (CRC). As a secondary aim, we performed parallel analyses of sigmoidoscopy.

Screening Colonoscopy and Risk for Incident Late-Stage Colorectal Cancer Diagnosis in Average-Risk Adults

The effectiveness of screening colonoscopy in average-risk adults is uncertain, particularly for right colon cancer. To examine the association between screening colonoscopy and risk for incident late-stage colorectal cancer (CRC). Nested case-control study. Four U.S. health plans. 1039 average-risk adults enrolled for at least 5 years in one of the health plans. Case patients were aged 55 to 85 years on their diagnosis date (reference date) of stage IIB or higher (late-stage) CRC during 2006 to 2008. One or 2 control patients were selected for each case patient, matched on birth year, sex, health plan, and prior enrollment duration. Receipt of CRC screening 3 months to 10 years before the reference date, ascertained through medical record audits. Case patients and control patients were compared on receipt of screening colonoscopy or sigmoidoscopy by using conditional logistic regression that accounted for health history, socioeconomic status, and other screening exposures. In analyses restricted to 471 eligible case patients and their 509 matched control patients, 13 case patients (2.8%) and 46 control patients (9.0%) had undergone screening colonoscopy, which corresponded to an adjusted odds ratio (AOR) of 0.29 (95% CI, 0.15 to 0.58) for any late-stage CRC, 0.36 (CI, 0.16 to 0.80) for right colon cancer, and 0.26 (CI, 0.06 to 1.11; P = 0.069) for left colon/rectum cancer. Ninety-two case patients (19.5%) and 173 control patients (34.0%) had screening sigmoidoscopy, corresponding to an AOR of 0.50 (CI, 0.36 to 0.70) overall, 0.79 (CI, 0.51 to 1.23) for right colon late-stage cancer, and 0.26 (CI, 0.14 to 0.48) for left colon cancer. The small number of screening colonoscopies affected the precision of the estimates. Screening with colonoscopy in average-risk persons was associated with reduced risk for diagnosis of incident late-stage CRC, including right-sided colon cancer. For sigmoidoscopy, this association was seen for left CRC, but the association for right colon late-stage cancer was not statistically significant.