Despite progress in the detection and treatment of colorectal cancer, there exist significant disparities between African Americans and whites in the areas of screening, staging, treatment, and survival.
Colorectal cancer afflicts African Americans at a higher rate than whites. For African American men, the rate is 68 per 100,000 vs. 55 per 100,000 for whites. For African American women, the rate is 53 per 100,000 vs. 41 per 100,000 for whites. The mortality rate for African American men and women is 50% higher than for their white counterparts!
There are a number of explanations for why African Americans have decreased survival rates with colorectal cancer compared to whites:
- African Americans have lower screening rates for colorectal cancer. This is most likely due to decreased access to high quality medical care in the African American community. The high cost of medical care and lack of adequate health insurance coverage are factors as well. Another contributing factor may in part be due to patients’ understanding of the rationale for screening which may be related to socioeconomic status and education level. Cultural beliefs and mistrust may also play a role.
- Cancer tends to appear at an earlier age. Colorectal cancer amongst African Americans tends to be more biologically aggressive. Younger African Americans have 10.7 more cases of colorectal cancer per 100,000 than whites. There is increasing acceptance that screening for colorectal cancer should begin at age 45 instead of 50 for African Americans because of the higher incidence and earlier onset of disease. This is supported by the American College of Gastroenterology who has endorsed colorectal screening for African Americans beginning at age 45.
- More advanced stage of cancer at diagnosis. This is in part due to the more aggressive biology of colorectal cancer as mentioned above. Additionally, African Americans are less likely to participate in and complete colorectal cancer screening procedures resulting in late-stage diagnosis, more difficult treatment, and decreased survival.
- Differences in biological behavior of polyps and colorectal cancer. African Americans who present with colorectal cancer tend to have more advanced cancer stages and more aggressive disease. African Americans also have an increased incidence of colorectal cancer in the right colon (ascending colon) which tends to be more difficult to evaluate at colonoscopy.
- African Americans tend to have other medical problems such as diabetes and heart disease, which affect one’s response to treatment. This is in part due to the decreased level of access to high quality medical care. Higher rates of obesity in the African American community likely also are contributing.
- Inadequate social support systems could play a role in decreased survival as well.
Several of the above reasons likely stem from the fact that high quality medical care is not as accessible in the African American communities as it is in white communities. A recent study by Al-Refaie and colleagues showed that if high-quality care is delivered to minority populations, they essentially do as well as whites.
In order to improve outcomes in the African American community, the gastroenterology and medical communities can have major impacts at many levels. These interventions can include:
- Greater access to high quality medical care in minority communities.
- Expanded patient education programs which discuss the benefits of screening as well as what is involved in undergoing a colonoscopy.
- Debunking the myths surrounding colonoscopy is important in increasing the acceptance of this life-saving procedure.
- Starting colorectal cancer screening at age 45 instead of 50 for African Americans.
- If colonoscopy is not readily available in the medical community, offer other screening tests such as stool tests to detect microscopic blood (FIT or Hemoccult), sigmoidoscopy, barium enema, or CT colonography.
Here’s to your colon health!
Frank Farrell, M.D.