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Update: Cancer disparities: Colorectal cancer in African Americans

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Contents

At a glance Clinical trials 
Update findings Guidelines
Context Questions for your doctor
What does this mean for me? Resources

 

UPDATE AT A GLANCE

What is this update about?

This report is about disparities in colorectal cancer rates, related deaths, and cancer screening in African Americans, as well as factors that may contribute to the disease in this population.

 

Why is this update important?

Colorectal cancer (CRC) is the third most common cancer diagnosed in African American adults. About 20,000 new cases were diagnosed in this population in 2019.

Rates for colorectal cancer diagnosis and death among African Americans declined over the past decade. Still, these rates are higher than rates among people of other races or ethnicities. The AACR updated the status of colorectal cancer in African Americans and disparities of the disease compared with other racial or ethnic groups. The update highlighted risk factors, screening, rates of diagnosis, treatment and deaths related to colorectal cancer among African Americans.

 

Update findings

The AACR Cancer Disparities Progress Report 2020 included the most recent research of colorectal cancer involving African Americans. The following topics and research findings were included in the report.

Screening of colorectal cancer in African Americans

  • Almost 20 percent of the disparity in colorectal cancer mortality rate between African Americans and white Americans is attributed to lower rates of screening among African Americans.
  • African Americans aged 50 and older are most likely to undergo screening for colorectal cancer of any non-white racial or ethnic group.
  • Factors that keep African Americans from being screened include:
    • Lack of awareness about colorectal cancer
    • Being unaware of the benefits of screening
    • Fear of a colonoscopy, fear of pain and financial concerns
    • Lack of insurance and access to care, and
    • Not receiving a health care provider’s recommendation to have screening
  • African Americans have a high prevalence of cancer on the right side of the colon, which includes the cecum, ascending colon and proximal transverse colon. These organs cannot be reached by flexible sigmoidoscopy screenings but can be reached by colonoscopy. (See the variety of colorectal cancer screening tests in Guidelines.)
  • Among African Americans with an identified gene alteration in genes linke to colorectal cancer risk, more are variants of uncertain significance are detected (where it is not clear if the mutation will increase disease risk or not) than among whites. This may reflect lack of focus or followup research on these genetic mutations.
     

Rates of colorectal cancer in African Americans

  • Approximately 20,000 new diagnoses of colorectal cancer occur annually in African Americans adults aged 18 and older.
  • African American men are 26 percent more likely to be diagnosed than African American women.
  • Rates of colorectal cancer decreased by roughly 3 percent per year in African Americans from 2005 to 2016.
     

Disparities between African Americans and white Americans

  • The overall rate of colorectal cancer is nearly 20 percent higher in African Americans.
  • The incidence of colorectal cancer before age 50  is twice as high in African Americans. The recent deaths of Chadwick Boseman at age 43 and Natalie Desselle-Reid at age of 53 serve as tragic examples of the disproportionate impact of early-onset CRC among the African American community.
  • Some early case of CRC may be due to hereditary forms of CRC including mutations in genes. On average, the rate of mutations (which increases risk of colorectal cancer) in African Americans is similar to white Americans. However, mutations may be more frequent among those with particular ancestries (e.g., people from Zimbabwe).
  • African Americans are more than four times likely to be diagnosed with proximal (right-sided) colon cancer, which is more aggressive than left-sided colon cancer.
     

Disparities between African Americans and all other racial and ethnic groups

  • Compared with all racial/ethnic groups, African Americans are more likely to receive an initial diagnosis of colorectal cancer when the disease is more advanced and harder to treat.
     

Treatment disparities in African Americans compared with non-Hispanic white Americans

  • African Americans are less likely to be recommended the right care for the type and of their cancer. As a result, they are less likely to receive surgical treatments, radiation and chemotherapy, which may greatly benefit their health and survival.
  • African Americans are less likely to participate in clinical trials for cancer treatment that may include access to new and beneficial therapies.
  • The following barriers are more likely to prevent African Americans from receiving colorectal cancer treatment:
    • Lack of health insurance coverage
    • Cost of services
    • Transportation difficulties
    • Lack of knowledge about colorectal cancer
       

Deaths due to colorectal cancer in African Americans

  • African Americans are most likely to die from colorectal cancer compared to individuals of any other race or ethnicity.
  • Each year an estimated 2,300 African American adults will die from colorectal cancer.
  • Only 60 percent of African Americans with colorectal cancer will live at least five years after diagnosis, compared with 66 percent of their white counterparts and 68 percent of their Asian American or Pacific Islander counterparts.
     

Factors that increase colorectal cancer risk for African Americans and contribute to

  • Smoking
    • Although African Americans and white Americans have similar rates of smoking, African Americans are three times more likely to smoke menthol cigarettes. According to the , menthol, which is used to mask the harsh taste of tobacco, likely poses a greater public health risk than nonmenthol cigarettes.
    • African American adults and children are two times more likely to be exposed to secondhand smoke than any racial or ethnic group.
  • Weight
    • African American adults (75 percent) are more likely to be overweight or obese than non-Hispanic white Americans (70 percent).
  • Diet
    • Although the quality of the African American diet has improved, research shows that they report a lower intake of whole grains, fruits, and vegetables than any other racial or ethnic group.
  • Physical Activity
    • African Americans (35 percent) are more likely to report no leisure-time physical activity than non-Hispanic white Americans.
  • Social and Economic Factors
    • Currently, 21 percent of African Americans live below the federal poverty level, compared with 8 percent for non-Hispanic white Americans. The incidence of colorectal cancer is 35 percent higher among African American men living in the poorest US counties than those living in the most affluent counties.
    • African Americans are twice as likely as white Americans to be uninsured. Individuals who lack health insurance have a higher risk of poor outcomes from cancer compared with those who are insured.
    • Systemic racial discrimination has been shown to contribute to poor physical and mental health among minorities and has been linked to increased cancer risk among African Americans.
  • Environmental Factors
    • African Americans and Hispanic Americans are more likely than any other race or ethnicity to be exposed to higher levels of pesticides and other household chemicals that have been linked to the development of colorectal cancer.
    • African Americans are more likely than non-Hispanic white Americans to be exposed to higher levels of outdoor air pollution, which is a known cancer-causing agent.

 

Context

Cancer disparities based on race and ethnicity are the results of many factors. Some disparities are due to factors that can be modified, such as smoking, while others may be due to the long history of racism in our society. This has resulted in unfavorable outcomes for African Americans and other historically marginalized racial and ethnic groups. These unfavorable outcomes include high poverty rates, lack of access to healthy foods and racial bias within our healthcare system—all of which can result in worse health and treatment outcomes.

 

What does this mean for me?

If you are African American, be aware that your risk of colorectal cancer may be higher than other people’s risk. Ask your doctor about factors that affect your risk and whether making any lifestyle changes or other steps can lower your risk. You may want to ask your doctor what your risk is given your personal or family history and what screenings are recommended. Under the Affordable Care Act, insurance companies are required to pay for colorectal cancer screening—in many cases with no out-of-pocket expenses—for people between the ages of 50 and 75. Image of colon showing how much of the colon can be seen by sigmoidoscopy compared with colonoscopy

Importantly, of all the screenings available, colonoscopy can prevent many cases of colorectal cancer by finding and removing abnormalities before they can become cancer. Although sigmoidoscopy can also find and remove polyps, this procedure uses a shorter scope that doesn’t examine the entire colon. It misses the more aggressive cancers that may develop in the right colon (first part of the colon). Speak with your doctor to decide which screening test is best for you.

Aspirin has also been shown to lower the risk for colorectal cancer, as well as heart disease. FORCE reviewed this in a recent XRAY review linked here. Ask your doctor if you might benefit from daily low-dose aspirin to lower your risk for both diseases.

If you have been diagnosed with cancer, it’s important to make sure that you are offered guideline-recommended care given your and type of cancer. Obtain a copy of your medical records and get a second opinion on your diagnosis and treatment plan.

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posted 4/27/21


References

American Cancer Association of Cancer Research, AACR Cancer Disparities Progress Report 2020

Siegel R, Miller K, Goding Sauer A, et al. Colorectal cancer statistics, 2020CA Cancer J Clin. 2020; 70(3):145-164. March 5, 2020. doi:10.3322/caac.21601

 

Disclosure

FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board prior to publication to assure scientific integrity.

This article is relevant for:

African Americans concerned about colorectal cancer

This article is also relevant for:

People newly diagnosed with cancer

People with a family history of cancer

Healthy people with average cancer risk

People with colorectal cancer

Be part of XRAY:

Expert Guidelines
Expert Guidelines

The U.S. government and many health organizations have recommendations for colorectal cancer screening and other preventative measures. Below are the recommendations from the American Cancer Society (ACS), the National Comprehensive Cancer Network (NCCN) and the U.S. Preventive Services Task Force ().


Screening Recommendations

 

ACS

NCCN

Recommended age to begin routine colorectal cancer screening for people at average risk for the disease

Age 45

Age 45

Age 45 -49
(Grade B)

Age 50 
(Grade A)

Recommended age to discontinue routine screening for those at average risk

Age 75

Age 75

Age 75

Recommends that screening for adults ages 76 to 85 be based on patient preferences, health status, and prior screening history.

Yes

Yes

Yes (Grade C)

Advises against colorectal cancer screening beyond 85 years of age

Yes

-

-

Recommended age to begin routine colorectal cancer screening for people at high risk* for the disease

Before age 45: specific age depends on risk factor

Before age 45: specific age depends on risk factor

-


*People with any of the following are considered high risk: 1) personal history of colorectal cancer or certain types of polyps, 2) family history of colorectal cancer, 3) personal history of inflammatory bowel disease, or 4) a confirmed or suspected hereditary colorectal cancer syndrome, such as familial adenomatous polyposis (FAP) or .


Colorectal cancer screening tests

Stool‐based tests are tests performed on a stool (feces) sample to help diagnose conditions affecting the digestive tract, including colorectal cancer. Like most screening diagnostics, the frequency of stool tests varies. Stool tests include:

Stool Test

Recommended frequency

Fecal protein test (FIT)

Once per year

Fecal blood test (gFOBT)

Once per year

Fecal test (FIT-DNA)

Once every 1 or 3 years

 

Structural (visual) examinations look inside the colon and rectum for areas that might be cancerous or have polyps. These include:

Structural examinations

Recommended frequency

Colonoscopy

Once per 10 years

CT colonography

Once per 5 years

Flexible sigmoidoscopy

Once per 5 years

Flexible sigmoidoscopy with FIT

Flexible Sigmoidoscopy every 10 years plus FIT every year


Importantly, of all the screenings available, colonoscopy can prevent many cases of colorectal cancer by finding and removing abnormalities before they can become cancer. Although sigmoidoscopy can also find and remove polyps, this procedure uses a shorter scope that doesn’t examine the entire colon. 

Insurance coverage for screening

Colorectal cancer screenings such as stool-based tests (see descriptions below) beginning at age 45 have been given a grade "A" or "B" by the U.S. Preventive Services Task Force (). This means that these services have shown effectiveness in detecting or preventing the disease. 

  • The Patient Protection and Affordable Care Act (ACA) requires that most health plans cover 100 percent of one colorectal cancer screening at its recommended frequency (see Colorectal cancer screening tests table below) with no out-of-pocket costs to patients who are age 45 and older—no matter their risk. 
  • Medicare beneficiaries—no matter their age—are allowed one colonoscopy covered at 100 percent every six years for those at average risk and one colonoscopy per 24 months for those at high risk.
  • Medicaid coverage of colorectal cancer screening varies by state. Individuals who qualify based on their state’s decision to expand Medicaid under the ACA are entitled to the same screening and preventive services as those who are covered by private insurance.

For individuals at increased risk, certain states require insurance coverage of colonoscopy beyond that required under the ACA. Check with your state insurance commission to determine if you live in one of these states.

Updated: 06/12/2022

Expert Guidelines
Expert Guidelines

According to the American Cancer Society and the National Comprehensive Cancer Network (NCCN), you may be able to lower your risk of colorectal cancer by doing the following: 

Screening

  • Undergoing recommended colorectal cancer screenings can help prevent colorectal cancer by identifying and removing abnormal growths before they can become cancerous. 

Lifestyle 

  • Getting to and staying at a healthy weight.
    • Being overweight or obese is a risk factor for colorectal cancer. 
  • Exercising regularly.
    • Physical activity has been shown to lower the risk of colorectal cancer as well as other serious diseases.
    • Adults should get at least 150 minutes of moderate-intensity activity (equal to a brisk walk) or 75 minutes of vigorous activity (makes your heartbeat and breathing faster and makes you sweat) each week, preferably spread throughout the week.
  • Eating a healthy diet.
    • Eating a variety of different vegetables and fruits, whole grains and fish or poultry is linked with a lower risk of colorectal cancer. Eating more processed foods and red meat is linked with a higher risk of colorectal cancer. The ACS recommends:
      • Eating at least 2½ cups of vegetables and fruits each day.
      • Eating less red meat (beef, pork and lamb) and less processed meat (bacon, sausage, luncheon meats and hot dogs).
      • Choosing bread, pasta and cereal made from whole grains instead of refined grains, and brown rice instead of white
      • Eating fewer sweets.
  • Avoiding tobacco.
  • Limiting alcohol consumption.
    • Alcohol can increase the risk for colorectal cancer, especially among men. Men should have no more than 2 drinks a day and women no more than 1. A standard serving of alcohol is: 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits.

Aspirin as a preventative measure

The United States Preventive Services Task Force () and NCCN support the use of daily low-dose aspirin as a preventative measure against colorectal cancer. Daily aspirin protects against colorectal cancer when it is taken at a low dose for at least five to 10 years. The and NCCN recommend the following:

  • Low-dose (81 mg) aspirin can be considered as a preventative measure for people ages 45 to 60 years who have elevated risk of cardiovascular disease and who have a life expectancy of at least 10 years.
  • The decision to offer aspirin should take into consideration the risk of bleeding, life expectancy and long-term compliance.

Updated: 02/06/2022

Questions To Ask Your Doctor
Questions To Ask Your Doctor

  • When should I begin routine screening for colorectal cancer?
  • What factors put me at risk for colorectal cancer?
  • What is the best treatment option for my colorectal cancer?
  • What factors put me at risk for poor treatment outcomes?
  • Would I be a good candidate for any clinical trials involving colorectal cancer treatment?

Open Clinical Trials
Open Clinical Trials

The following are studies looking at colorectal cancer screening or prevention.  ​​​​​

Other colorectal cancer screening and prevention studies may be found here.

Updated: 11/27/2021

Open Clinical Trials
Open Clinical Trials

The following clinical research studies focus on addressing in cancer. 

Updated: 11/03/2022

Who covered this study?

US News & World Report

Cancer Health Disparities Continue This article rates 4.0 out of 5 stars

Yahoo! News

AACR report on cancer disparities reveals harsh truths and a call to action This article rates 4.0 out of 5 stars

Cancer Health

AACR Releases First Cancer Disparities Progress Report This article rates 3.0 out of 5 stars

How we rated the media

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