African Americans face the highest death rate for most cancers compared to any other racial and ethnic group, and the disparities associated with colon cancer are particularly glaring.
African Americans are 20 percent more likely to develop the cancer than other groups and 40 percent more likely to die from it, according to the American Cancer Society.
Despite the striking data, many primary care physicians are unaware of the extent of the risk colon cancer poses to African Americans — a gap that needs to be addressed, experts say.
During this National Colorectal Cancer Awareness Month, Becker's asked five experts what the area of focus should be when it comes to reducing the health disparities associated with colon cancer.
From ramping up efforts to educate both patients and providers, to dedicating more time to navigating patients through the screening process, here are their responses:
Editor's note: Responses, lightly edited for grammar and clarity, are presented in alphabetical order.
Carl Crawford, MD. Gastroenterologist at New York Presbyterian and Weill Cornell Medicine (New York City):
It's a complicated question because a lot of factors are involved here. First, we have to consider the awareness of the patient. Traditionally, there hasn't been enough education surrounding colorectal cancer screenings or symptoms, especially among African American patients who are disproportionately affected by colorectal cancer. There's room for improvement when it comes to educating both patients and providers on the different types of screening tests available.
Early symptom recognition is another critical component. Blood in the stool, for example, shouldn't be waved off as hemorrhoids. There's been cases where patients with symptoms say they weren't told by their providers to see a gastroenterologist. That's a gap that needs to be addressed and it also highlights the increased need for provider awareness regarding colorectal cancer disparities.
Lastly, given the increased prevalence of colorectal cancer among those under age 50, providers should emphasize early screening, starting at age 45.
While having a colorectal cancer awareness month is nice, there needs to be a wider, ongoing effort overall on increasing education surrounding disparities, symptoms and screening.
Lewis Foxhall, MD. Vice President of Health Policy at the University of Texas MD Anderson Cancer Center (Houston):
Colorectal cancer, the second leading cause of cancer-related death in the U.S., has long been associated with disparities in deaths and newly diagnosed individuals. While outcomes have improved over time, gaps persist, with African Americans being impacted to a greater degree. Various factors, such as exposure to smoking and obesity, are associated with these inequities. Socio-economic conditions, including insurance coverage in particular, contribute to persistent disparities.
Great strides in reducing mortality and morbidity due to colon cancer can still be obtained by a dedicated focus on dissemination of evidence-based screening opportunities to men and women in vulnerable populations. A collaborative approach by cancer centers, community health facilities and primary care centers, such as Federally Qualified Health Centers, provides a proven strategy to deliver screenings and navigation to diagnosis and treatment, leading to a reduction – and hopefully elimination – of disparities.
Mark Friedman, MD. Gastroenterologist at Moffitt Cancer Center (Tampa, Fla.):
Many providers are unaware that African Americans develop colon cancer at an earlier age and have a higher mortality rate from it. So, the first step is increasing provider education and making sure they are following the appropriate guidelines.
Many African Americans may also be unaware of the increased danger that colon cancer poses to them and their loved ones, so it’s critical that targeted educational tools are provided to them. We need to encourage patients to discuss family medical history so that they know if they are at an increased risk.
This can sometimes be a taboo subject amongst African American patients. We need to make sure screening is available to anyone who wants it and not make it cost prohibitive. And we need to de-stigmatize the complexity and dangers of colonoscopy so that fewer patients are fearful of it.
Trilokesh Kidambi, MD. Gastroenterologist and Director of the Colon Cancer Screening Program at City of Hope Comprehensive Cancer Center (Los Angeles):
It is an unfortunate reality that disparities in colorectal cancer incidence, mortality, treatment and our fundamental understanding of the natural history of the disease itself continue to exist. For example, we have seen improvements in the overall incidence and mortality for some groups like our African American patients, but the rates are still higher in African Americans than any other racial or ethnic group. We know many minority ethnic groups are more likely to present with earlier onset cancer at a later stage and that screening rates are lower in these populations.
I firmly believe that increased uptake in on-time and consistent screening will help reduce these disparities and lead to better outcomes. I practice in a racially and ethnically diverse region at a comprehensive cancer center that emphasizes a culturally centered approach to care, including instructions in several languages and the consistent use of in-person translators. As a result, we have had good adherence to screening recommendations and have been able to prevent colorectal cancer in many patients. I believe the emphasis should be prevention through screening using a culturally centered and focused manner.
Mary Reid, PhD. Chief of Cancer Screening, Survivorship and Mentorship at Roswell Park Comprehensive Cancer Center (Buffalo, N.Y.):
There is definitely a lot that can be done to improve colorectal cancer screening rates in general, but especially in populations which are particularly at risk or have access issues. Our experiences have been twofold. One is that, for those folks who have a primary care physician, and have been identified as eligible for colon cancer screening, there are a lot of barriers to actually getting the screening.
There are issues of health literacy in terms of understanding what the role of the colon is and understanding the implications of cancer. There are different kinds of tests, some home-based. With the colonoscopy, which is more definitive, sometimes patients can't quite manage the stress of getting scheduled and having someone from their family go with them, getting a ride and getting time off of work. There are barriers, but we find that if we are working with community providers, if we actually help navigate the patient, we've had incredible success with populations that don't speak English, with African American populations and Hispanic populations.
We've seen success when we bridge the gap between the primary care physician and actually getting the patient screened — and that kind of navigation has led to, in some cases, a 20 percent increase in complete colon screening in some of our clinics around the city.
One, it's a complicated test. It's not just like getting an image, and the other part is there is a lot of misunderstanding and mistrust with the health system. So even when patients know they're eligible, oftentimes, they're given a phone number that they don't call. That's not an effective way to get people through this screening process, especially with patients who have language barriers, health literacy barriers — they need much more navigation to complete the test. For people who don't have a primary care physician, it's really a struggle. They don't get the information and they don't get the recommendations. In many aspects, getting people into clinics and seeing primary care physicians starts at the community level.
This year has been really difficult all around. We know that nationally, colon cancer screening has decreased in the range of about 80 percent to 90 percent, and the communities most affected by that decrease in colon cancer screening are the communities that are most impacted by COVID-19. What we expect this year is that people who have symptoms of colon cancer — pain, bloody stool or changes in their bowel habits — aren't getting in to see primary care practices because those are busy, and they're putting it off.
Down the line, we would expect to see increases of about 15 percent in colorectal cancer mortality. So right now especially, this awareness month is very important to highlight the benefits of screening at the community level and to build up those navigation programs.