Colorectal cancer:
How do we approach health
disparities?
Marta L. Davila, MD, FASGE
University of Texas MD Anderson
Cancer Center
Colorectal cancer (CRC)
Facts
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Third most common cause of cancer
Second leading cause of cancerrelated deaths in men and women in
the US
An estimated 143,000 cases of CRC
are expected to occur in 2012
American Cancer Society. Cancer facts and figures 2012.
Atlanta: American Cancer Society; 2012
Colorectal cancer
Facts
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51, 690 deaths from CRC are
expected to occur in 2012
Americans have a 5% lifetime risk for
CRC
Rare before age 40 in both men and
women, with 90% of cases occurring
after age 50
Colorectal cancer
Facts
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Incidence of CRC has been declining
in the US by 2-3% per year over the
last 15 years
CRC screening probably accounts
for this decline by early detection
and removal of polyps
Good evidence shows that screening
reduces mortality from CRC
Polyp to Cancer Progression
A. Sessile polyp
B. Pedunculated polyp
C. Colon cancer
Figure available at: http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease3&organ=6&disease=36&lang_id=1.
Accessed March 18, 2009.
Colorectal cancer
Facts
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Modifiable factors associated with
increased risk of CRC:
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Obesity
Physical inactivity
Diet high in red or processed meat
Alcohol consumption
Long-term smoking
Low intake of fruits and vegetables
Early identification of patients with
genetic conditions
Cancer health disparities
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Definition: “..adverse differences noted in
cancer epidemiology that exist among
specific groups in the U.S.”
Further defined by new cases (incidence),
deaths (mortality) and associated
psychosocial and financial burden
These populations are characterized by
age, education, ethnicity/race, gender,
income and geographic location
Cancer disparities
Causes
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Social
Economic
Cultural
Health system factors
Inequities in work, wealth, education,
housing, and barriers to prevention,
early detection and treatment
services
American Cancer Society. Colorectal Cancer Facts and Figures. 2011-2013
Atlanta: American Cancer Society. 2011
American Cancer Society. Colorectal Cancer Facts and Figures. 2011-2013
Atlanta: American Cancer Society. 2011
CRC disparities
African-Americans
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Dietary / Nutritional factors
Rates of physical inactivity
Variability in screening rates
Lower use of diagnostic testing
Decreased access to high-volume
hospitals and subspecialists
Genetic susceptibilities
Cancer biology
American Cancer Society. Colorectal Cancer Facts and Figures. 2011-2013
Atlanta: American Cancer Society. 2011
Colorectal cancer screening
guidelines
CRC screening guidelines
US Preventive Services Task Force (USPSTF)
• For average-risk adults, screening should begin at age 50 and
continue until age 75
• CRC screening in adults 76 to 85 years should be individualized
Test
Time interval
Fecal occult blood test
(FOBT)
Annual
Flexible sigmoidoscopy
5 years
Colonoscopy
10 years
Ann Intern Med 2008;149:627-37
CRC screening guidelines
American Cancer Society (ACS) , US Multi-society Task Force on
Colorectal Cancer (USMSTF) and the American College of Radiology
(ACR)
• Average-risk adult should start screening at age 50
Test
Time interval
Flexible sigmoidoscopy
5 years
Optical colonoscopy
10 years
Double-contrast barium enema
5 years
CT colonography
5 years
Fecal occult blood test (guaiac
or immunochemical based)
Annual
Stool DNA test
Uncertain
Ann Intern Med 2012;156:378-386
American Cancer Society. Colorectal Cancer Facts and Figures. 2011-2013
Atlanta: American Cancer Society. 2011
CRC screening
Barriers
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Cost and lack of access to health
care
Physician variability regarding
screening recommendations
Poor transmission of the benefits
and risks of not getting screened
Personal barriers
Fear, embarrassment, distrust of the
medical community
Strategies to increase CRC
screening
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Prompt one-on-one discussion about the
potentially life-saving importance of
screening
Remove financial barriers to screening
Help patients navigate through the
healthcare system
Use educational prompts to educate the
community about Colonoscopy and other
forms of screening
Strategies to reduce CRC
disparities
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Support increased funding for colorectal
cancer programs and research at the NIH
Support the CDC Colorectal cancer
Control Program
 Goal: to increase CRC screening rates
in adults >50 years to 80%
Support community programs targeting
racial/ethnic minorities
Summary
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Colorectal Cancer is a common, yet preventable
disease that affects 140,000 individuals annually
Colorectal Cancer mortality has declined over
the past 3 decades largely due to increased
screening
Disproportionately higher cancer incidence and
mortality rates in minority populations may be
directly related to barriers to screening
Identifying these barriers is key to improved
outcomes