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Otis Webb Brawley, MD

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Disparties in Colorectal Cancer

Posted: 03/ 2/2012 12:47 pm

Last week, just before the start of National Colorectal Cancer Month, a study in the New England Journal of Medicine made news for a finding most people probably assumed we already knew. The more than two decade-long study suggests that colonoscopy screening and aggressive removal of polyps (non-cancerous colonic growths) not only decreases long term risk of colon cancer, but also decreases risk of colon cancer death. As hopeful as this finding is, the news is tempered by the fact that irrationality in our healthcare system means many Americans will benefit less or perhaps not at all from this potentially lifesaving screening.

At first, one might be pleased that colorectal cancer death rates have dropped by 42 percent over thirty years. This decline is due to the application of significant new knowledge, including better treatments and the ability to remove polyps before they turn into cancer. It is estimated that more than 1.1 million colorectal cancer survivors are alive today.

But the harsh reality is not everyone is benefiting from new knowledge about screening, diagnosis, and treatment of colorectal cancer. In fact, during the 30-year period when the risk of death from colon cancer among all Americans dropped 42 percent, African Americans experienced only an 18 percent decline in risk of death from colorectal cancer.

Indeed, African Americans have the highest risk of death from colorectal cancer of any racial/ethnic group in the U.S. In 2008, the most recent year for which data is available, Black men were 1.5 times more likely to die of colorectal cancer compared to white men. Black women were 1.4 times more likely to die of it than white women.

How could this be happening? Is it biology? Are African Americans doing something wrong? The best evidence we have tells us it's something far more complicated. In the U.S. today, a country built on the promise that all of us should share equally in the rich benefits of citizenship, we have tremendous disparities in quality of colorectal cancer treatment. Studies show that racial/ethnic minorities, the poor, and the poorly educated are getting less than optimal care.

Some of the best designed and conducted cancer clinical trials ever done show that colon cancer screening saves lives. We know that screening adults over age 50 saves lives. We know that nearly half of Americans over 50 of all races are not getting colorectal cancer screening. We also know that among those diagnosed with colorectal cancer a substantial minority of patients of all races do not receive high quality care. There is data to show that racial minorities and poor whites are less likely to get adequate quality care.

Of the more than 49,000 deaths due to colorectal cancer that will occur in 2012, at least 10,000 lives, likely far more, could have been saved if existing screening and treatment technologies had been provided to those people over the past decade. It is an outrage that lives are being lost, not due to the absence of science, but because of the lack of application of known science.

Let me review what is known about controlling colorectal cancer. Success requires attention to its known causes, early diagnosis, and appropriate treatment.

Controllable factors that increase risk of colorectal cancer include: a lack of physical activity, obesity, a high calorie diet, consumption of large amounts of red meats and processed meats, and smoking and excessive alcohol use.

The triad of lack of physical activity, obesity, and poor diet is a leading cause of chronic disease, including diabetes, cardiovascular disease, orthopedic injury and a number of cancers, not just colorectal cancer. Centers for Disease Control data show that rates of obesity have grown dramatically over the past several decades. Now more than a third of all adults are obese. This portends toward increase rates of a number of chronic diseases including colorectal cancer.

In 2008, the American Cancer Society in collaboration with the American College of Radiology, the American College of Gastroenterology, the American Society of Gastrointestinal Endoscopy and the American Gastroenterological Association published consensus guidelines for colorectal cancer screening.

These guidelines recommend that men and women aged 50 and older at average risk use of any of a number of screening tests that have been shown to decrease mortality. These include fecal occult blood testing, stool DNA testing, double contrast barium enema, computed tomographic colonography (virtual colonoscopy), sigmoidoscopy, and colonoscopy. These tests need to be used at varying intervals some annually, some as rare as every ten years.

In certain areas of the US, screening with colonoscopy has gained great popularity. All of these tests save lives and the focus needs to be on getting all adults age 50 and above some type of high quality colorectal screening and appropriate treatment more so than advocacy of any particular test.

Studies show that experienced physicians generally provide better care. The patients or the patient's advocate, often a family member, needs to be interested in and engaged in treatment and treatment decisions. Patient interest can often bring out the best in even the best of doctors.

We have the tools, and the science proves that they work. The challenge is to ensure that everybody can benefit from them.