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Dr. Sands:
Health disparities have challenged communities in multiple ways, including within the field of medicine. And for patients with colorectal cancer, these disparities continue to impact clinical outcomes. What are some of the challenges leading to these health disparities? And what are some ways we can overcome them?
Welcome to Project Oncology on ReachMD. I'm Dr. Jacob Sands. And joining me today to talk about colorectal cancer screening guidelines and disparities is Dr. Edith Mitchell, Clinical Professor of Medicine and Medical Oncology Director of the Center to Eliminate Cancer Disparities and the Associate Director of Diversity Affairs at the Sidney Kimmel Cancer Center at Thomas Jefferson University. Dr. Mitchell is also co-leader of the Health Equity Committee of the ECOG-ACRIN Cancer Research Group and past President of the National Medical Association.
Dr. Mitchell, thank you for joining me today.
Dr. Mitchell:
Thank you, Dr. Sands, for the invitation to join you today.
Dr. Sands:
Let's start out with just an overview of those guidelines and how has this impacted colorectal cancer mortality rates.
Dr. Mitchell:
Absolutely. First of all, there has been a continuous decline in colorectal cancer death rates or mortality over the last three decades. So colorectal cancer is the most common cancer in men and women in the United States. Colorectal cancer screening efforts are directed toward removal of polyps and adenomas and sessile serrated lesions and detection of early-stage colorectal cancer where, if polyps are removed, they can no longer form a cancer, and if cancers are detected, the outcomes and results of treatment are better. So there's been a continuous decline of approximately 1.7 to 3.2 percent respectively per year, so we have made substantial declines in overall mortality rate. The decline began in the mid-1980s and was accelerated in the 2000s. It is believed to be driven by a number of factors, including risk factors, early detection of cancer through colorectal cancer screening, and removal of precancerous polyps with colonoscopy, in addition to advances in surgical and treatment approaches.
Most colorectal cancers develop through adenoma-carcinoma sequence and presenting opportunities for us to intervene and prevent cancer by removing the precancerous polyps and lesions, and therefore, these lesions will never develop into cancer. Approximately, 70% of sporadic colorectal cancers develop from polyps and about 25 percent from sessile serrated lesions, through this pathway, so colorectal screening is very important, for removal of adenomas. Certain screening modalities, such as colonoscopy, sigmoidoscopy and others, with the stool-based testing, can detect these cancers. It's also important that if a cancer or a polyp is found in an individual, where there is a hereditary component, we can, therefore, screen other family members, which enhances the effectiveness of screening. So screening for colorectal cancer is very important and has significantly contributed to the decline in colorectal cancer mortality rates in this country.
Dr. Sands:
And now taking a step back and looking at just all individuals with an increased risk of colorectal cancer, such as due to family history or polyps, what is the recommended guidelines for these individuals?
Dr. Mitchell:
So, guidelines are very important, and the guidelines are determined for individuals with average risk, but if the individual or patient has more than average risk either based on family history or hereditary syndromes or other family members with not only colorectal cancers but other, GI malignancies, the guidelines don't specifically address those individuals. And depending on the abnormalities that may be found in hereditary, cancers in other populations, we will want to give individual recommendations.
Dr. Sands:
Now, if we can focus on at-risk subgroups, what kind of variations are we seeing with clinical outcomes?
Dr. Mitchell:
Certainly, there are individuals who are at higher risk for development of colorectal cancer—that's the incidence rates—and others with the mortality rates. It's well-recognized that African-Americans have a higher incidence rate—that means development of colorectal cancer—and higher death rates or mortality rates. African-Americans overall have a 20 percent higher incidence rate than other racial or ethnic groups in this country and a 40 percent higher death rate or mortality rate. In fact, African-American men have a 47 percent higher mortality rate from colorectal cancer in this country, and that occurs for many reasons.
There are opportunities where individuals do not have access to care. There might not be a healthcare center convenient to their location with the history of redlining in this country where African-Americans could only receive loans for purchasing houses in certain areas. These areas, consequently might have healthcare institution deserts; there's nothing nearby. There are also food deserts where there is a lack of good food access and stores and others where they can buy healthy food. So patients are told, "eat a healthy diet," but there is nothing healthy that is in their community.
There's also the lack of access to care, social determinants of health, increased out-of-pocket costs where it costs an individual to take a day off from work where they don't get paid and therefore have to travel to extensive distances in order to seek medical attention and certainly, for those institutions, and healthcare facilities providing colonoscopy and other methods of access to care. There's also the insurance issue in the use of stool-based testing such that if an individual, utilizes a stool-based test and that test is positive, the colonoscopy to confirm that test, might not be covered by some insurances.
Dr. Sands:
For those just tuning in, you’re listening to Project Oncology on ReachMD. I’m Dr. Jacob Sands, and I’m speaking with Dr. Edith Mitchell about colorectal screening guidelines. It is overwhelming the multiple different ways that some of our communities are really being impacted. You've outlined different angles of health disparities. And so, how are these health disparities impacting the care for patients with colorectal cancer and the outcomes for these individuals?
Dr. Mitchell:
There has been a tremendous impact on individuals who develop colorectal cancer and thereby need treatment, and many of the treatment diagnostic procedures are not available to black patients. Many of the opportunities for participating in clinical trials, are not available. In fact, Dr. Sands, there was a patient related outcomes study completed asking information about participating in clinical trials, and the most frequent answers were "Oh yes, black patients wanted to participate in clinical trials but were never asked." So we have a double-edged sword here that 1) we need to offer the participation in clinical trials, and 2) we need to make the clinical trials, available to patients.
It's well-recognized that we have done a lot of research over the last few decades that have produced great results in outcomes for treatment of colorectal cancer, but they are not uniformly provided to black patients. In fact, there are data from the FDA showing that those studies presented to the FDA for evaluation had only about 1.6% of black participants, so we need more opportunities for participation in diagnostic clinical trials where we're looking at, tumor markers and genomic markers that predict for 1) risk of benefit and 2) giving specific data regarding cancers and therefore treatment modalities. So we need to make these available to black patients, and we need to, therefore, have methods of getting the patients into clinical trials, so we need more education, education of clinicians to offer the trials and to spend time discussing it with patients, so that we can have equity in the opportunities for black patients. For clinicians, it is recognized that for practicing black doctors in this country, less than 5% of practicing clinicians are black although the number of blacks in the United States population is approximately 13%, so getting more individuals into clinical positions, not just for physicians but pharmacists, nurses and others, because for people who understand minority populations, who can converse with minority populations, therefore, very important to have more of these practicing clinicians, in the United States. Also having navigators and community health workers who can really be an extension of our offices because they live in the communities, they understand the communities, they know the communities, and they know the process.
Dr. Sands:
There is so much to discuss, but unfortunately that is all we have time for today. I want to thank my Guest, Dr. Edith Mitchell, for joining me to share her insights on colorectal disparities and health equities. Dr. Mitchell, absolutely wonderful having you on the program today.
Dr. Mitchell:
Thank you.
Dr. Sands:
I’m Dr. Jacob Sands. To access this and other episodes in our series, visit ReachMD.com/Project-Oncology, where you can Be Part of the Knowledge. Thanks for listening.
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Widespread health disparities have led to challenges in colorectal cancer screening. What's causing these disparities—and what are some ways we can overcome these obstacles? To dive into this topic, Dr. Jacob Sands is joined by Dr. Edith Mitchell from Thomas Jefferson University to discuss these disparities and how they may be impacting clinical outcomes.
Widespread health disparities have led to challenges in colorectal cancer screening. What's causing these disparities—and what are some ways we can overcome these obstacles? To dive into this topic, Dr. Jacob Sands is joined by Dr. Edith Mitchell from Thomas Jefferson University to discuss these disparities and how they may be impacting clinical outcomes.
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