Socioeconomic status and the risk of colorectal cancer: an analysis of more than a half million adults in the National Institutes of Health-AARP Diet and Health Study

[Influence of socio-economic factors and education level on colorectal cancer in the Moroccan population]

Introduction

Colorectal cancer is a true scourge and a major public health problem. The main purpose of this study was to identify the impact of socio-economic factors and education level on the onset of colorectal cancer and of diagnosis stage in the Moroccan population.

Methods

We conducted a case-control study of patients treated for cancer at the Mohammed VI center from January 2015 to January 2017. We interviewed, on a prospective basis and using a structured and pre-tested questionnaire, 225 patients and 225 eligible and consenting subjects.

Results

The average age of patients was 55.49± 14.06 years. In 53% of cases diagnosis was made at early-stage colorectal cancer while in 47% at advanced stage. In addition, a detailed analysis of the studied population according to the socio-economic status (SES), showed a proportion of 25.33% (patients) versus 17.33% (control) in the low SES group, while, equivalent rates (45.33% patients versus 45.33% control) in the middle SES group. In the high SES group, the rate of patients was only 16.89% patients versus 37.34% control (p = 0.0001). Education and SES were strongly correlated with diagnosis stage, with a significant difference. Then 36.44% of illiterate patients were diagnosed in advanced stage versus 5.33% of patients who had completed their secondary education level or university course (p = 0.02). Similarly 20.45% of patients with low SES were diagnosed in late stage versus 5.33% of patients with higher SES (p = 0.03).

Conclusion

Our results highlight that the risk of developing colorectal cancer is strongly dependent on the education and the socio-economic status of patients. A more thorough investigation is needed to clarify the causes of this inequality.

Trends of colorectal cancer incidence by education and socioeconomic status in Finland

Background: The aim of this study was to investigate if the incidence of colorectal cancer (CRC) is associated with education and socioeconomic status (SES) in Finland, and if there are any changes in incidence differences between the groups over the period 1976-2014.Material and methods: CRC cases (N = 77,614) were retrieved from the Finnish Cancer Registry and linked with information on the education level and SES from Statistics Finland. We used Poisson regression model to quantify differences in incidence rates between the groups, and to assess changes over calendar time.Results and conclusions: Colon cancer incidence was higher among the highly educated, than in those with basic education. Similar differences were observed by SES in men. Incidence rates increased steeply over time among men with basic education (from 16.7/100,000 in 1976-1979 to 31.8 in 2010-2014), resulting in narrowed differences between the groups (p < .001). Incidence trends of proximal and distal colon and rectal cancer in men showed similar patterns. Heterogeneity across time periods by SES was observed only in colon cancer incidence in men (p = .009). No such large differences were detected in women. Steep increase in colon cancer incidence in men with basic education, and the respective persistent high incidence in the highly educated highlights the importance of focusing the preventive measures on modifiable lifestyle factors in order to reduce CRC incidence and to narrow the educational and socioeconomic health differences.

Regional Differences in Colorectal Cancer Mortality Between 2000 and 2013 in Republic of Korea

OBJECTIVE

Colorectal cancer (CRC) is the fourth most common site for cancer death in the Republic of Korea. The aim of this study was to describe the trends of colorectal cancer mortality by region.

METHODS

CRC mortality trends in Republic of Korea were described by region using a Joinpoint regression model in both sexes. The annual percent changes (APCs) were calculated for each segment. Visualization of the changes in mortality rate of colorectal cancer death rates by 16 geographic areas in both sexes between 2000-2004 and 2009-2013 were also conducted.

RESULTS

CRC mortality rates of men showed decreasing trend after increase in Daegu, Gyeongsangnam-do, and Chungcheongbuk-do between 2000 and 2013 based on the joinpoint model, while Gwangju, Jeollabuk-do, Jeollanam-do, and Gyeongsangbuk-do showed increase in CRC mortality during the same period. For women, CRC mortality of Seoul, Incheon, Daejeon, and Gyeongsangnam-do started to decrease in 2005, 2003, 2007, and 2006, respectively. The mortality rate for CRC in the eastern regions, which had relatively low rates of CRC among men in 2000 through 2004, reached a level similar to that in the northwestern regions of 2009 through 2013, while the highest CRC mortality rates in women was observed in Chungcheongbuk-do.

CONCLUSIONS

Reduction in CRC mortality varied across 16 metropolitan cities and provinces in men, and the visualization pattern showed that the east side of South Korea had the least progress in mortality reduction.

Low colorectal cancer survival in the Mountain West state of Nevada: A population-based analysis

Colorectal cancer (CRC) is the third greatest cancer burden in the United States. The remarkably diverse Mountain West state of Nevada has uncharacteristically high CRC mortality compared to other Western states. We aimed to study the determinants of the CRC excess burden by using data from the Nevada Central Cancer Registry from 2003-2013. Five-year cause-specific age-adjusted survival from colorectal cancer was calculated and stratified by sex, race/ethnicity and region of Nevada. Cox Proportional Hazards regression modelling was used to study the impact of demographic, social, and clinical factors on CRC survival in Nevada, assessing follow-up as accurately as possible. The extent to which differences in survival can be explained by receipt of stage-appropriate treatment was also assessed. 12,413 CRC cases from 2003-2013 in Nevada were analyzed. Five-year CRC survival was low: 56.0% (95% CI: 54.6-57.5) among males and 59.5% (95% CI: 58.0-61.1) among females; significantly lower than national 5-year survival of 65.1% and 66.5%, respectively. Low survival was driven by populous Southern Nevada; after adjustment for all covariates, Southern Nevadans were at 17% higher risk of death than their counterparts in Northwestern Nevada (HR:1.17; 95% CI:1.08-1.27). Many patients did not receive stage-appropriate treatment, although this only partly explained the poor survival, uniformly low for every race/ethnicity in Nevada. The observed disparity for this one state within a single nation merits public health attention; regardless of the state or region of residence, all Americans deserve equal opportunity for optimum health outcomes in the face of a cancer diagnosis. The current study provides baseline information critical to clinicians, public health professionals, and all relevant stakeholders as they attempt to discern why Nevada's outcomes are vastly divergent from its neighboring Western states and make plans for remediation.

Exploring geographical differences in the incidence of colorectal cancer in the Norwegian Women and Cancer Study: a population-based prospective study

PURPOSE

Norway has experienced an unexplained, steep increase in colorectal cancer (CRC) incidence in the last half-century, with large differences across its counties. We aimed to determine whether geographical distribution of lifestyle-related CRC risk factors can explain these geographical differences in CRC incidence in Norwegian women.

METHODS

We followed a nationally representative cohort of 96,898 women with self-reported information on lifestyle-related CRC risk factors at baseline and at follow-up 6-8 years later in the Norwegian Women and Cancer Study. We categorized Norwegian counties into four county groups according to CRC incidence and used Cox proportional hazard models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk factors. We used the Karlson, Holm, and Breen (KHB) method of mediation analysis to investigate the extent to which the risk factors accounted for the observed differences in CRC incidence between counties.

RESULTS

During an average of 15.5 years of follow-up, 1875 CRC cases were diagnosed. Height (HR=1.12; 95% CI 1.08, 1.17 per 5 cm increase); being a former smoker who smoked ≥10 years (HR=1.34; 95% CI 1.15, 1.57); or being a current smoker who has smoked for ≥10 years (HR=1.28; 95% CI 1.12, 1.46) relative to never smokers was associated with increased CRC risk. Duration of education >12 years (HR=0.78; 95% CI 0.69, 0.87) vs ≤12 years, and intake of vegetables and fruits >300 g (HR=0.90; 95% CI 0.80, 0.99) vs ≤300 g per day were associated with reduced CRC risk. However, these risk factors did not account for the differences in CRC risk between geographical areas of low and high CRC incidence. This was further confirmed by the KHB method using baseline and follow-up measurements (b=0.02, 95% CI -0.02, 0.06, p=0.26).

CONCLUSION

Lifestyle-related CRC risk factors did not explain the geographical variations in CRC incidence among Norwegian women. Possible residual explanations may lie in heritable factors.

Reliability of Contrast CT and Positron Emission Tomography in Post-Surgical Colorectal Cancer and Its Association with Obesity

BACKGROUND

Post-surgical recurrence of cancer colon occurs in one-third of patients within the first two years, so early detection is important. The assessment of the therapeutic response is important to change protocol strategy. Positron emission tomography/computed tomography PET/CT, a valuable tool gives both metabolic and anatomic information for whole-body regions. Obesity is an important risk factor for colorectal cancer.

AIM

To evaluate post-surgical and therapeutic colorectal cancer by PET/CT and study obesity association to its prognosis.

METHODS

This was a prospective study involved 93 patients with, post-surgical colorectal cancer examined by PET/CT, then follow up after 4-6 months.

RESULTS

There was a statistically significant difference between PET/CT and contrast CT. The sensitivity& the specificity were (96.4%-100% & 92.3%-98.2%) for PET/CT and (84.2%-90.2% & 76.5%-85.4%) for contrast CT respectively. Post-therapeutic follow up showed; progressive course (24.5%), stationary course (26.4%), partial regression (28.3%) and complete regression course (20.8%). Obesity is a risk factor for progression with highly statistically significant to treatment response. Obese patients had a progressive or stationary course of the disease. Also, there was a highly statistically significant association between total abdominal fat & visceral abdominal fat areas with good response of treatment.

CONCLUSION

PET/CT is the most appropriate imaging technique to detect any recurrence or metastases in post-surgical colorectal cancer with high sensitivity and specificity comparing to CT. Obesity is a predictor risk factor for prognosis of the disease, as generally and abdominally (total & visceral fat) had an association with therapeutic response.

Socioenvironmental adversity and risk of prostate cancer in non-Hispanic black and white men

Non-Hispanic black (NHB) men experience higher risk of prostate cancer than other racial/ethnic groups, and it is possible that socioenvironmental (SE) adversity and resulting stress may contribute to this disparity. Data from the Southern Community Cohort Study were used to evaluate associations between SE adversity and perceived stress in relation to prostate cancer risk, overall and by race/ethnicity and grade. Between 2002 and 2009, 26,741 men completed a questionnaire, from which an 8-item SE adversity composite was created (covering socioeconomic status, residential environment, and social support/buffers). Two items from the Perceived Stress Scale were assessed. With follow-up through 2011, 527 prostate cancer cases were diagnosed. In multivariable models, each one-unit increase in the SE adversity composite was associated with increased prostate cancer risk among non-Hispanic white (NHW) men (HR 1.23; 95% CI 1.02-1.48) and reduced risk among NHB men (HR 0.89; 95% CI 0.82-0.95) (p interaction: 0.001). This pattern held for low grade, but not high grade, cancers although power was limited for the latter. Perceived stress variables were associated with increased risk of prostate cancer among NHW men, but not among NHB men. Results do not support the hypothesis that SE adversity my underlay the racial disparity in prostate cancer, over and above that of covariates, including healthcare utilization.

Diagnosis of Primary Colorectal Carcinoma with Primary Breast Cancer: Associations or Connections?

Introduction

Although once very uncommon, multiple primary malignant neoplasms (MPMN) are becoming an increasingly popular subject in medical literature. With 182,000 new diagnoses per annum, breast cancer is the most frequently diagnosed cancer amongst women in the United States. Colorectal cancer remains the second most commonly diagnosed cancer in females, and the third in males worldwide.

Methods

In order to gather literature on synchronous and metachronous occurring breast and colon cancer, we searched PubMed using keywords such as 'colorectal cancer', 'breast cancer', and 'MPMN'. We searched through case reports, case series, clinical trials, letters to the editor, and retrospective series. We included any manuscript in English published between January 1990 and January 2019. The articles featured patients who had primary colorectal cancer with primary breast cancer. Articles featuring patients with more than two malignancies or malignancies other than colorectal and breast cancer were excluded. Furthermore, any metastatic cancers were excluded as well. This narrowed our search down from over 100 manuscripts to just four. 

Results

Fortunately, the prognosis was found to be no different for these patients with MPMN assuming diagnosis and treatment are performed in a timely fashion. Additionally, it appears that although a patient with one primary cancer is at a greater risk for the development of a second cancer, it is still an odd phenomenon and thus an unlikely occurrence.

Conclusion

Detection of one cancer increases the odds of detecting another cancer. Hence, it is important to consider the possibility of a synchronous tumor in a patient with a newly diagnosed colon tumor, as well as to not only consider disease recurrence when following up post-resection.

Rational targeting of population groups and residential areas for colorectal cancer screening

BACKGROUND

Sociodemographic and spatial disparities in incidence and mortality burden of colorectal cancer (CRC) are important to consider in the implementation of population screening, in order to achieve expected benefit and not increase health inequities. Analytic methods should be adapted to provide rational support for targeted interventions.

METHODS

CRC incidence rates by tumor stage (I-IV) and location (colon vs. rectum) were analyzed for the time period 2008-2016 within a screening-relevant age interval of 55-74 years for the population of South and West Sweden, where screening is planned for. The study population was stratified by sex, country of birth, educational level (for Swedish-born citizens) and residential area. We also estimated disparities in excess mortality from CRC across groups of patients accordant to relevant population groups.

RESULTS

The analyses were based on 8961 patients with a first CRC diagnosis. There were marked socioeconomic gradients in the stage II-IV CRC incidence rates among Swedish-born men and women. Compared to men with high educational level, the incidence rate ratios (IRRs) of stage II, III, and IV CRC in men with low educational level were 1.38 (95% confidence interval 1.18, 1.62), 1.09 (0.95, 1.26), and 1.18 (1.02, 1.37), respectively. In women, the corresponding figures were 1.26 (1.06, 1.51), 1.19 (1.01, 1.39), and 1.45 (1.20, 1.80). The groups of patients with low educational level showed relatively high excess mortality burdens from CRC.

CONCLUSIONS

Our analytic approach provided rational support for targeted intervention when implementing CRC screening, aiming at optimizing participation in groups with low educational level.

Associations of demographic, socioeconomic, self-rated health, and metastasis in colorectal cancer in Iran

Background: Metastasis in Colorectal Cancer (CRC) is important because of the costs imposed on the individual. Self-Rated Health (SRH) can be useful for preventing cancer. Considering the role of Socio-Economic Status (SES) in CRC, our study was conducted to evaluate the relationship between demographic, SES, SRH, and metastasis of this type of cancer in Markazi province, Iran. Methods: This cross-sectional, descriptive study (April to July 2018) was conducted on 411 patients suffering from CRC. These patients were hospitalized in one of the medical centers affiliated to Arak University of Medical Sciences (Arak, Iran), and with non-random sampling (available sampling) they were imported to the study. A reliable and valid questionnaire about levels of SES and SRH was filled by patients. For analyzing the data, Binomial logistic regression and chi-square tests were executed using Stata 11 software. Results: The mean age was 60.01 years. According to the results of this study, as compared with poorest SES patients, the OR estimate of metastasis was 0.80 (95% CI: 0.36, 1.78) among the richest SES patients, in patients with age of >60 years was 9.92 (95% CI: 1.53, 64.39) in comparison with patients with age of <40 years, in male patients was 3.26 (95% CI: 1.76, 6.04) compared with female ones; in divorced/widowed patients was 0.52 (95% CI: 0.11, 2.51) in comparison with single ones; among those with academic level of education was 4.28 (95% CI: 1.49, 12.26) compared with illiterate patients; and compared with poor SRH-age of patients, was 3.78 (95% CI: 2.09, 6.85) among those with good SRH-age. Conclusion: Patient's education and SES are important variables in metastasis and SRH of CRC in Iranian patients. All diagnostic tests and medical possibilities should be available for all individuals with adequate interventions. Patient's education and awareness should also be increased.

Participation and Ease of Use in Colorectal Cancer Screening: A Comparison of 2 Fecal Immunochemical Tests

INTRODUCTION

The impact of fecal immunochemical test (FIT)-based colorectal cancer (CRC) screening on disease incidence and mortality is affected by participation, which might be influenced by ease of use of the FIT. We compared the participation rates and ease of use of 2 different FITs in a CRC screening program.

METHODS

There were two study designs within the Dutch CRC screening program. In a paired cohort study, all invitees received 2 FITs (OC-Sensor, Eiken, Japan, and FOB-Gold, Sentinel, Italy) and were asked to sample both from the same stool. Ease of use of both FITs was evaluated by a questionnaire. In a randomized controlled trial, invitees were randomly allocated to receive one of the 2 FITs to compare participation and analyzability.

RESULTS

Of 42,179 invitees in the paired cohort study, 21,078 (50%) completed 2 tests and 20,727 (98%) returned the questionnaire. FOB-Gold was reported significantly easier to use. More participants preferred FOB-Gold (36%) than OC-Sensor (5%), yet most had no preference (59%; P < 0.001). In the randomized trial, 936 of 1,923 invitees (48.7%) returned the FOB-Gold and 940 of 1,923 invitees (48.9%) returned the OC-Sensor, a difference of -0.2% (confidence interval, -3.4% to 3.0%), well within the pre-specified 5% noninferiority margin (P = 0.001). Only one FOB-Gold (0.1%) and 4 OC-Sensors (0.4%) were not analyzable (P = 0.18).

CONCLUSIONS

Although FOB-Gold was significantly but marginally considered easier to use than OC-Sensor, the number of analyzable tests and the participation rates in organized CRC screening are not affected when either of the FITs is implemented as a primary screening test.

Outcome disparities in colorectal cancer: a SEER-based comparative analysis of racial subgroups

PURPOSE

Previous studies of ethnic disparities in colorectal cancer (CRC) have focused mainly on patients of Caucasian and African-American descent. We aimed to evaluate outcomes for a range of races, representing a broader demographic of the US population.

METHODS

The Surveillance, Epidemiology, and End Results database was queried to identify patients with CRC diagnosed between 1994 and 2014. We performed unadjusted Kaplan-Meier test and multivariable covariate-adjusted Cox models to calculate the overall and CRC-specific survival of patients according to their race.

RESULTS

We identified 401,723 patients diagnosed with CRC between 1994 and 2014. Overall survival (OS) and CRC-specific survival were compared across different races stratified by age, sex, marital status, disease stage and grade, and undergoing surgery as a treatment. Overall, Asian/Pacific Islanders and Hispanics had improved CRC-specific survival compared to Whites (HR = 0.873, 95%CI 0.853-0.893, P < .001, and HR = 0.958, 95%CI 0.937-0.979, P < .001, respectively). Blacks had the worst CRC-specific survival outcomes when compared to Whites (HR = 1.215, 95%CI 1.192-1.238, P < .001). Racial disparity persisted when looking at two different time periods (1994-2003 and 2004-2014).

CONCLUSIONS

Asians/Pacific Islanders have improved outcomes from CRC compared to other races. Multifactorial, including genetic, environmental, and socioeconomic factors appear to influence outcomes and need to be addressed separately in order to reduce racial disparities among patients with CRC.

Splenic Injury with Subsequent Pleural Effusion: An Underreported Complication of Colonoscopy

Colorectal cancer is a leading cause of morbidity and mortality worldwide. As such, there are recognized guidelines in the screening of this preventable cancer. There are differences in opinion regarding screening recommendations between the European and United States Cancer Prevention Societies. Screening colonoscopy is an option for routine screening for colorectal cancer in asymptomatic adults. It is a day procedure that is conducted both in hospital and specialized outpatient endoscopy suites. Serious harm is in the region of 3 per 1,000 examinations [Am J Gastroenterol. 2016 Aug; 111(8): 1092–101]. Splenic injury is a rare complication of colonoscopy whose frequency is unclear. Conservative management of splenic injury is desirable in order to preserve immunocompetence. We present a case in which a previously healthy 59-year-old female developed a splenic injury and later pleural effusion after screening colonoscopy.

The association of socioeconomic status with quality of life in cancer patients over a 6-month period using individual growth models

PURPOSE

Studies examining longitudinal associations between socioeconomic factors and quality of life (QoL) in cancer patients are rare. This study investigates changes in QoL over a 6-month period.

METHODS

Four hundred forty-two cancer patients (mean age 64, SD = 11, 70% male) completed standardized questionnaires at the beginning (t1) and end (t2) of their hospital stay and 3 (t3) and 6 months (t4) thereafter. QoL was assessed with the EORTC QLQ-C30 core questionnaire. Mixed effect models were employed to analyze individual changes in QoL in relation to socioeconomic status (education, income, job status) over the four timepoints. Age, sex, cohabitation, disease and treatment factors, and comorbidity were included as covariates in the models.

RESULTS

Income was a predictive factor for QoL. Patients with a low income had 8.8 percentage points (PP) lower physical, 4.9 PP lower emotional, and 11.4 PP lower role functioning. They also had 6.6 PP lower global QoL. Lower social functioning (6.2 PP) was found in patients with higher education or university degrees compared with those who were less educated or had not undergone an apprenticeship. Income also influenced trajectories of role functioning. There was no evidence that primary or secondary education and job type were related to QoL.

CONCLUSIONS

The fact that income is negatively associated with many aspects of quality of life should be considered during and after treatment with a focus on patients with special needs.

Postoperative Outcomes of Screen-Detected vs Non-Screen-Detected Colorectal Cancer in the Netherlands

Importance

The nationwide fecal immunochemical test-based screening program has influenced surgical care for patients with colorectal cancer (CRC) in the Netherlands, although these implications have not been studied in much detail so far.

Objective

To compare surgical outcomes of patients diagnosed as having CRC through the fecal immunochemical test-based screening program (screen detected) and patients with non-screen-detected CRC.

Design, Setting, and Participants

This was a population-based comparative cohort study using the Dutch ColoRectal Audit and analyzed all Dutch hospitals performing CRC resections. Patients who underwent elective resection for CRC between January 2011 to December 2016 were included.

Interventions

Colorectal cancer surgery.

Main Outcomes and Measures

Postoperative nonsurgical complications, postoperative surgical complications, postoperative 30-day or in-hospital mortality, and complicated course (postoperative complication resulting in a hospital stay >14 days and/or a reintervention and/or mortality). A risk-stratified comparison was made for different postoperative outcomes based on screening status (screen detected vs not screen detected), cancer stage (I-IV), and for cancer stage I to III also on age (aged ≤70 years and >70 years) and American Society of Anesthesiologists score (I-II and III-IV). To determine any residual case-mix-corrected differences in outcomes between patients with screen-detected and non-screen-detected cancer, univariable and multivariable logistic regression analyses were performed.

Results

In total, 36 242 patients with colon cancer and 17 416 patients with rectal cancer were included for analysis. Compared with patients with non-screen-detected CRC, screen-detected patients were younger (mean [SD] age, 68 [5] vs 70 [11] years), more often men (3777 [60%] vs 13 506 [57%]), and had lower American Society of Anesthesiologists score (American Society of Anesthesiologists score III+: 838 [13%] vs 5529 [23%]). Patients with stage I to III colon cancer who were screen detected had a significantly lower mortality and complicated course rate compared with non-screen-detected patients. For patients with rectal cancer, only a significant difference was found in mortality rate in patients with a cancer stage IV disease, which was higher in the screen-detected group. Compared with non-screen-detected colon cancer, an independent association was found for screen-detected colon cancer on nonsurgical complications (adjusted odds ratio, 0.81; 95% CI, 0.73-0.91), surgical complications (adjusted odds ratio, 0.80; 95% CI, 0.72-0.89), and complicated course (adjusted odds ratio, 0.80; 95% CI, 0.71-0.90). Screen-detected rectal cancer had significantly higher odds on mortality.

Conclusions and Relevance

Postoperative outcomes were significantly better for patients with colon cancer referred through the fecal immunochemical test-based screening program compared with non-screen-detected patients. These differences were not found in patients with rectal cancer. The outcomes of patients with screen-detected colon cancer were still better after an extensive case-mix correction, implying additional underlying factors favoring patients referred for surgery through the screening program.

Cost-effectiveness of a patient navigation intervention to increase colonoscopy screening among low-income adults in New Hampshire

BACKGROUND

Colonoscopy is the most widely used colorectal cancer (CRC) screening test in the United States. Through the detection and removal of potentially precancerous polyps, it can prevent CRC. However, CRC screening remains low among adults who are recommended for screening. The New Hampshire Colorectal Cancer Screening Program implemented a patient navigation (PN) intervention to increase colonoscopy screening among low-income patients in health centers in New Hampshire. In the current study, the authors examined the cost-effectiveness of this intervention.

METHODS

A decision tree model was constructed using Markov state transitions to calculate the costs and effectiveness associated with PN. Costs were calculated for the implementation of PN in a statewide public health program and in endoscopy centers. The main study outcome was colonoscopy screening completion. The main decision variable was the incremental cost-effectiveness ratio associated with the PN intervention compared with usual care.

RESULTS

The average cost per screening with PN was $1089 (95% confidence interval, $1075-$1103) compared with $894 with usual care (95% confidence interval, $886-$908). Among patients who were navigated, approximately 96.2% completed colonoscopy screening compared with 69.3% of those receiving usual care (odds ratio, 11.2; P <. 001). The incremental cost-effectiveness ratio indicated that 1 additional screening completion cost approximately $725 in a public health program and $548 in an endoscopy center with PN compared with usual care, both of which are less than the average Medicare reimbursement of $737 for a colonoscopy procedure.

CONCLUSIONS

PN was found to be cost-effective in increasing colonoscopy screening among low-income adults in the New Hampshire Colorectal Cancer Screening Program, even at the threshold of current Medicare reimbursement rates for colonoscopy. The results of the current study support the implementation of PN in statewide public health programs and endoscopy centers.

Ten-Year Change in Neighborhood Socioeconomic Deprivation and Rates of Total, Cardiovascular Disease, and Cancer Mortality in Older US Adults

Low neighborhood socioeconomic status has been linked to adverse health outcomes. However, it is unclear whether changing the neighborhood may influence health. We examined 10-year change in neighborhood socioeconomic deprivation in relation to mortality rate among 288,555 participants aged 51-70 years who enrolled in the National Institutes of Health-AARP Diet and Health Study in 1995-1996 (baseline) and did not move during the study. Changes in neighborhood socioeconomic deprivation between 1990 and 2000 were measured by US Census data at the census tract level. All-cause, cardiovascular disease, and cancer deaths were ascertained through annual linkage to the Social Security Administration Death Master File between 2000 and 2011. Overall, our results suggested that improvement in neighborhood socioeconomic status was associated with a lower mortality rate, while deterioration was associated with a higher mortality rate. More specially, a 30-percentile-point reduction in neighborhood deprivation among more deprived neighborhoods was associated with 11% and 19% reductions in the total mortality rate among men and women, respectively. On the other hand, a 30-point increase in neighborhood deprivation in less deprived neighborhoods was associated with an 11% increase in the mortality rate among men. Our findings support a longitudinal association between changing neighborhood conditions and mortality.

Disparities in colorectal cancer between Northern and SouthernSweden - a report from the new RISK North database

BACKGROUND

Geographic cancer health disparities have been reported in Sweden. The disparities are not fully understood, but may be attributed to differences in exposure to risk factors as well as differences in health care, socioeconomics and demography. The aim of this study was to describe the new nationwide population based RISK North database and its potential by analysing health disparities in colorectal cancer between Northern and Southern Sweden.

METHODS

Cancer-specific data from the National Cancer Quality Registers for colorectal, gastric and oesophageal cancer and brain tumours were linked to several nationwide registers hereby creating a new database - RISK North. To exemplify the potential of RISK North, we analyzed differences in colorectal cancer incidence, mortality and survival in relation to gender, age, cohabitation and education between Northern and Southern Sweden 2007-2013.

RESULTS

In colon cancer, the age-adjusted incidence per 100.000 was lower in Northern than Southern Sweden, 35.9 in the North vs. 41.1 in the South (p < .01); mortality rates were 11.0 vs. 12.2 (p < .01). For rectal cancer, incidence rates were 17.6 vs. 19.7 (p < .01) and mortality rates 5.33 vs. 5.89 (p = .07), respectively. The largest difference in incidence was demonstrated for colon cancer among individuals >79 years old (190. vs. 237, i.e., ∼20%). Survival in colon cancer was higher in Southern Sweden, HR 0.92 (0.87-0.98) adjusted for age, gender, co-habiting, education and m-stage at diagnosis. No difference in survival was seen for rectal cancer.

CONCLUSIONS

The new RISK North database enabled analysis of cancer disparities between Northern and Southern Sweden. The incidence of colorectal cancer were lower in the North of Sweden whereas colon cancer survival was higher in the South. These differences can be further analysed utilising the RISK North database.

Ten-year change in neighborhood socioeconomic status and colorectal cancer

BACKGROUND

A growing body of research has demonstrated that individuals who live in neighborhoods with more severe socioeconomic deprivation may have higher risks for colorectal cancer (CRC). However, previous studies have examined neighborhood socioeconomic status (SES) at only 1 point in time, and it is unclear whether changes in neighborhood SES also can influence the risks of CRC.

METHODS

Cox regression analysis was used to examine different trajectories of change in neighborhood SES over 10 years in relation to the incidence of CRC among 266,804 participants (ages 51-70 years) in the National Institutes of Health-AARP Diet and Health Study. Eligible participants reported living in the same neighborhood at baseline (1995-1996) and from 2004 to 2006 according to a follow-up questionnaire. Changes in neighborhood SES were measured between 1990 and 2000 by SES indices derived from Census data. Neighborhoods were grouped into 4 categories based on median SES indices in 1990 and 2000 (low-low, low-high, high-low, and high-high).

RESULTS

Compared with residents whose neighborhoods were in the higher SES group at both time points (reference category), those whose neighborhoods were consistently in the low SES group had a 7% higher risk of developing CRC (hazard ratio, 1.07; 95% confidence interval, 1.00-1.14). Moreover, the risk of CRC was 15% higher (hazard ratio, 1.15; 95% confidence interval, 1.02-1.28) for those living in neighborhoods with decreasing SES (high-low) over time.

CONCLUSIONS

The current findings suggest that exposure to consistently low SES neighborhoods and/or a decrease in neighborhood SES over a period of time may be associated with higher risks of CRC.

Multidisciplinary team intervention associated with improved survival for patients with colorectal adenocarcinoma with liver or lung metastasis

BACKGROUND AND OBJECTIVES

To investigate whether multidisciplinary team (MDT) intervention is associated with improved survival for patients with colorectal adenocarcinoma with liver or lung metastasis (CRA-LLM).

METHODS

We enrolled 161 consecutive patients with histologically confirmed CRA-LLM at Taipei Medical University-Wan Fang Hospital between January 2007 and December 2017. In total, 75 patients with CRA-LLM received MDT intervention, and 86 patients did not receive MDT intervention. To evaluate prognostic factors for overall death, we performed univariate and multivariate Cox regression analyses of the overall death rate in all patients. Overall survival rates were calculated using the Kaplan-Meier method, and Kaplan-Meier survival curves were compared using the log-rank test (P < .001).

RESULTS

A multivariate Cox regression analysis of the overall death rate in patients with CRA-LLM showed that age ≤ 65 years, systemic chemotherapy, curative-intent treatments, and MDT intervention are strong prognostic factors. The adjusted hazard ratio of death risk for age ≤ 65 years, systemic chemotherapy, curative-intent treatments, and MDT intervention were 0.60 (95% confidence interval [CI], 0.40-0.92; P = .019), 0.19 (95% CI, 0.12-0.32; P = .001), 0.25 (95% CI, 0.13-0.50; P = .001), and 0.40 (95% CI, 0.25-0.65; P = .001), respectively. The 3-year overall survival rates in patients with CRA-LLM receiving MDT intervention and not receiving MDT intervention were 48.75% and 24.21%, respectively.

CONCLUSION

MDT intervention is associated with improved survival for patients with CRA-LLM.

Association between oral health and colorectal adenoma in a screening population

Although periodontal disease and gastrointestinal tract health are closely associated, few studies have investigated whether periodontitis is a risk factor for colorectal adenoma. The aim of this study was to investigate whether there is an association between periodontitis and the risk of colorectal adenoma in asymptomatic healthy people.From January 2013 to October 2015, we retrospectively enrolled 42,871 patients who underwent health screening at Kangbuk Samsung Hospital in South Korea. Demographic and clinical data were collected before colonoscopy. We calculated the odds ratio (OR) for adenoma in these patients.The median age was 39.3 ± 8.7 years and 70.4% of the patients were men; 32.5% had a body mass index (BMI) 25.0 kg/m. The frequency of adenoma was 12% (n = 5136). A higher risk of adenoma was associated with the following factors: BMI 25.0 kg/m (OR 1.51, 95% confidence interval [CI]: 1.42-1.61), current smoker (OR 1.51, 95% CI: 1.42-1.61), former smoker (OR 1.28, 95% CI: 1.19-1.37), periodontitis (OR 1.95, 95% CI: 1.82-2.0), moderate alcohol intake (OR 1.8, 95% CI: 1.69-1.93), and heavy alcohol intake (OR 2.67, 95% CI: 2.24-3.18).Being male or a former or current smoker, alcohol intake above the moderate level, and periodontitis increase the risk of colorectal adenoma. These findings suggest that controlling oral disease is important to the prevention and management of colorectal adenoma. The findings of this study could be applied to risk stratification and colorectal cancer prevention programs, including screening guidelines.

Short-term postoperative outcomes of colorectal cancer among patients with chronic liver disease: a national population-based study

OBJECTIVE

Patients with colorectal carcinoma (CRC) with pre-existing chronic liver disease (CLD) had a significantly higher 30-day mortality after CRC surgery compared with healthy controls. This study investigated the factors associated with postoperative complications and in-hospital mortality in patients with CRC with coexisting CLD (excluding cirrhosis) who underwent colorectal surgery.

DESIGN

A retrospective, observational, population-based study.

SETTING

Data were sourced from the National Inpatient Sample database, a part of the Healthcare Cost and Utilisation Project.

PARTICIPANTS

This study analysed 7463 inpatients with CRC who underwent colorectal surgery on admission between 2005 and 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint of this study was the prevalence of postoperative complications, and the secondary endpoint was in-hospital mortality.

RESULTS

In the CLD group, 36.27% of patients had chronic hepatitis C, 28.36% had non-alcoholic fatty liver disease and 31.19% had other types of CLD. The median hospital stay was 7.0 (5.0-10.0) days in patients with no postoperative complications vs 17.0 (10.0-26.0) days, 8.0 (6.0-12.0) days, 8.0 (6.0-17.0) days, 9.0 (8.0-14.0) days and 10.5 (7.0-17.0) days for patients with postoperative infection, postoperative bleeding, cardiac arrest/heart failure, respiratory complications and digestive complications, respectively (all p<0.05). The presence of CLD was significantly associated with higher risk of postoperative bleeding (adjusted OR (aOR)=1.64, 95% CI 1.15 to 2.34, p=0.007). The presence of CLD (aOR=1.98, 95% CI 1.39 to 2.82, p<0.001) and length of hospital stay (aOR=1.06, 95% CI 1.04 to 1.08, p<0.001) were significantly associated with higher risk of in-hospital mortality. However, hyperlipidaemia was associated with a significantly lower risk of mortality (aOR=0.46, 95% CI 0.28 to 0.75, p=0.002).

CONCLUSIONS

Postoperative complications prolonged the length of hospital stay. The presence of CLD and hyperlipidaemia were important factors impacting postoperative complications and in-hospital mortality in patients with CRC with underlying CLD.

Severity of chronic periodontitis and risk of gastrointestinal cancers: A population-based follow-up study from Taiwan

The present study aimed to assess the association between the severity of chronic periodontitis and the risk of gastrointestinal (GI) cancers by investigating whether severe chronic periodontitis (CP), rather than mild CP, correlates with an increased risk of total or individual GI cancers.Adults (≥18 years) with mild and severe CP were identified from a random sample of 2 million insured patients in the National Health Insurance Research Database (2001-2010). After propensity score matching, 25,485 individuals, each with mild or severe CP, were included for comparison. The primary endpoint was the incidence of total or individual GI cancers, including cancers of the esophagus, stomach, small intestine, colon/rectum, and pancreas. Cox proportional hazard models with the robust aggregated sandwich estimator were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) after adjusting for known risk factors.GI cancers occurred in 275 individuals with mild CP and 324 individuals with severe CP. After adjusting for known risk factors, severe CP was not associated with an increased risk of total GI cancer relative to mild CP (HR: 0.99, 95% CI: 0.84-1.16) or individual GI cancers, including esophageal (HR: 1.15, 95% CI: 0.62-2.15), gastric (HR: 1.01, 95% CI: 0.68-1.49), small intestinal (HR: 0.70, 95% CI: 0.22-2.22), colorectal (HR: 0.95, 95% CI: 0.78-1.16), and pancreatic cancers (HR: 0.90, 95% CI: 0.47-1.75).Severe CP was not associated with an increased risk of total or individual GI cancers when compared with mild CP.

Determining Risk of Colorectal Cancer and Starting Age of Screening Based on Lifestyle, Environmental, and Genetic Factors

BACKGROUND & AIMS

Guidelines for initiating colorectal cancer (CRC) screening are based on family history but do not consider lifestyle, environmental, or genetic risk factors. We developed models to determine risk of CRC, based on lifestyle and environmental factors and genetic variants, and to identify an optimal age to begin screening.

METHODS

We collected data from 9748 CRC cases and 10,590 controls in the Genetics and Epidemiology of Colorectal Cancer Consortium and the Colorectal Transdisciplinary study, from 1992 through 2005. Half of the participants were used to develop the risk determination model and the other half were used to evaluate the discriminatory accuracy (validation set). Models of CRC risk were created based on family history, 19 lifestyle and environmental factors (E-score), and 63 CRC-associated single-nucleotide polymorphisms identified in genome-wide association studies (G-score). We evaluated the discriminatory accuracy of the models by calculating area under the receiver operating characteristic curve values, adjusting for study, age, and endoscopy history for the validation set. We used the models to project the 10-year absolute risk of CRC for a given risk profile and recommend ages to begin screening in comparison to CRC risk for an average individual at 50 years of age, using external population incidence rates for non-Hispanic whites from the Surveillance, Epidemiology, and End Results program registry.

RESULTS

In our models, E-score and G-score each determined risk of CRC with greater accuracy than family history. A model that combined both scores and family history estimated CRC risk with an area under the receiver operating characteristic curve value of 0.63 (95% confidence interval, 0.62-0.64) for men and 0.62 (95% confidence interval, 0.61-0.63) for women; area under the receiver operating characteristic curve values based on only family history ranged from 0.53 to 0.54 and those based only E-score or G-score ranged from 0.59 to 0.60. Although screening is recommended to begin at age 50 years for individuals with no family history of CRC, starting ages calculated based on combined E-score and G-score differed by 12 years for men and 14 for women, for individuals with the highest vs the lowest 10% of risk.

CONCLUSIONS

We used data from 2 large international consortia to develop CRC risk calculation models that included genetic and environmental factors along with family history. These determine risk of CRC and starting ages for screening with greater accuracy than the family history only model, which is based on the current screening guideline. These scoring systems might serve as a first step toward developing individualized CRC prevention strategies.

Occlusive stenosis - atypical presentation of right colon cancer

Colorectal cancers are one of the most frequent malignancies worldwide. Significant differences are described in relation to the location of tumors within the colon. Thus, between right and left colon cancer there are epidemiological, clinical, genetic, evolutionary and prognostic differences. Considering these premises, right and left colon cancers can be seen as distinct pathological entities. In right colon cancer the initial phases are often asymptomatic and the presence of symptoms is in relation to advanced phases and complications. We report the case of a 64-year-old man with no significant medical history who was admitted and operated as an emergency for stenotic and perforated tumor of the right colon. Operative exploration revealed distended small bowel loops and caecum up to the ascending colon where a stenosing tumor is found. The tumor extends to a small bowel loop and also exhibit a perforation. Right hemicolectomy was performed, with favorable postoperative evolution and discharge on 7th day.

Socioeconomic and ethnic inequities within organised colorectal cancer screening programmes worldwide

OBJECTIVE

Colorectal cancer (CRC) screening programmes can reduce CRC mortality. However, the implementation of a screening programme may create or exacerbate socioeconomic and ethnic health inequities if participation varies by subgroup. We determined which organised programmes characterise participation inequities by socioeconomic and ethnic subgroups, and assessed the variation in subgroup participation among programmes collecting group-specific data.

DESIGN

Employing a literature review and survey among leaders of national or regional screening programmes, this study identified published and unpublished data on participation by socioeconomic status and ethnicity. We assessed programmes offering faecal occult blood tests (FOBT) for screening. Primary outcome was screening participation rate.

RESULTS

Across 24 organised FOBT-screening programmes meeting the inclusion criteria, participation rates ranged from 21% to 73%. Most programmes (13/24, 54%) did not collect data on participation by socioeconomic status and ethnicity. Among the 11 programmes with data on participation by socioeconomic status, 90% (28/31 publications) reported lower participation among lower socioeconomic groups. Differences across socioeconomic gradients were moderate (66% vs 71%) to severe (35% vs 61%). Only six programmes reported participation results by ethnicity. Ethnic differences were moderate, though only limited data were available for evaluation.

CONCLUSIONS

Across organised CRC screening programmes worldwide, variation in participation by socioeconomic status and ethnicity is often not assessed. However, when measured, marked disparities in participation by socioeconomic status have been observed. Limited data were available to assess inequities by ethnicity. To avoid exacerbating health inequities, screening programmes should systematically monitor participation by socioeconomic status and ethnicity, and investigate and address determinants of low participation.

Neighborhood disadvantage and racial disparities in colorectal cancer incidence: a population-based study in Louisiana

PURPOSE

Colorectal cancer (CRC) continues to demonstrate racial disparities in incidence and survival in the United States. This study investigates the role of neighborhood concentrated disadvantage in racial disparities in CRC incidence in Louisiana.

METHODS

Louisiana Tumor Registry and U.S. Census data were used to assess the incidence of CRC diagnosed in individuals 35 years and older between 2008 and 2012. Neighborhood concentrated disadvantage index (CDI) was calculated based on the PhenX Toolkit protocol. The incidence of CRC was modeled using multilevel binomial regression with individuals nested within neighborhoods.

RESULTS

Our study included 10,198 cases of CRC. Adjusting for age and sex, CRC risk was 28% higher for blacks than whites (risk ratio [RR] = 1.28; 95% confidence interval [CI] = 1.22-1.33). One SD increase in CDI was associated with 14% increase in risk for whites (RR = 1.14; 95% CI = 1.10-1.18) and 5% increase for blacks (RR = 1.05; 95% CI = 1.02-1.09). After controlling for differential effects of CDI by race, racial disparities were not observed in disadvantaged areas.

CONCLUSION

CRC incidence increased with neighborhood disadvantage and racial disparities diminished with mounting disadvantage. Our results suggest additional dimensions to racial disparities in CRC outside of neighborhood disadvantage that warrants further research.

Statins dose-dependently exert a significant chemopreventive effect on colon cancer in patients with chronic obstructive pulmonary disease: A population-based cohort study

Purpose

We evaluated the chemopreventive effect of statins on colon cancer in patients with chronic obstructive pulmonary disease (COPD) and identified the statin exerting the strongest chemopreventive effect.

Methods

Using the National Health Insurance Research Database, we identified patients who received a COPD diagnosis in Taiwan between January 1, 2001, and December 31, 2012, and included them in the study cohort. Each patient was followed to assess the colon cancer risk and protective factors. A propensity score was derived using a logistic regression model to estimate the effect of statins by accounting for covariates predicted during the intervention (statins). To examine the dose–response relationship, we categorized statin doses into four groups in each cohort [<28, 28–90, 91–365, and >365 cumulative defined daily dose].

Results

Compared with the statin nonusers, the adjusted hazard ratio (aHR) for colon cancer decreased in the statin users (aHR = 0.52, 95% confidence interval = 0.44, 0.62). Hydrophilic statins exerted a stronger preventive effect against colon cancer. Regarding the statin type, lovastatin, pravastatin, and fluvastatin nonsignificantly reduced the colon cancer risk in the patients with COPD. Compared with the statin nonusers, the aHRs for colon cancer decreased in the individual statin users (rosuvastatin, simvastatin, and atorvastatin: aHRs = 0.28, 0.64, and 0.65, respectively). In the sensitivity analysis, statins dose-dependently reduced the colon cancer risk.

Conclusions

Statins dose-dependently exert significant chemopreventive effects on colon cancer in patients with COPD, with rosuvastatin exerting the largest chemopreventive effect.

Age-related rates of colorectal cancer and the factors associated with overall survival

Background

The purpose of this study was to identify differences in both demographic and pathologic factors associated with the age-related rates of colorectal cancer (CRC) and overall survival (OS).

Methods

The National Cancer Data Base (NCDB), 2004-2013, was queried for patients with CRC. Patients were stratified by age (≤50 vs. ≥60 years). Multivariable analysis was performed to identify factors associated with OS.

Results

A total of 670,030 patients were included; 488,121 with colon, and 181,909 with rectal or rectosigmoid cancer. For colon cancer, patients ≤50 years had higher proportions of pathologic stage III and IV disease than patients ≥60 (III: 33.7% vs. 28.6%, IV: 25.5% vs. 14.3%, respectively; P≤0.001). Similar differences were found for patients with rectal cancer (III: 35.8% vs. 28.6%, IV: 16.5% vs. 11.6%, respectively for age ≤50 and ≥60 years; P≤0.001). More aggressive pathologic factors were identified in the ≤50 cohort and were associated with worse OS, including higher tumor grade, lymphovascular invasion (LVI), perineural invasion (PNI), and elevated serum carcinoembryonic antigen (CEA). Disparities associated with OS were also identified for both colon and rectal cancer. For patients ≤50 with CRC, African-American and Hispanic race, lower income and lower education were associated with increased risk of mortality compared to the ≥60 cohort.

Conclusions

There are clear differences in biological factors and in racial and socioeconomic disparities of patients with early onset CRC. Earlier screening should be seriously considered in patients under 50 years who are African-American and Hispanic, as these populations present with more aggressive and advanced disease.

Characterizing the neighborhood obesogenic environment in the Multiethnic Cohort: a multi-level infrastructure for cancer health disparities research

PURPOSE

We characterized the neighborhood obesogenic environment in the Multiethnic Cohort (MEC) by examining the associations of obesity with attributes of the social and built environment, establishing a multi-level infrastructure for future cancer research.

METHODS

For 102,906 African American, Japanese American, Latino, and white MEC participants residing predominately in Los Angeles County, baseline residential addresses (1993-1996) were linked to census and geospatial data, capturing neighborhood socioeconomic status (nSES), population density, commuting, food outlets, amenities, walkability, and traffic density. We examined neighborhood attributes and obesity (body mass index ≥ 30 kg/m2) associations using multinomial logistic regression, adjusting for individual-level (e.g., demographics, physical activity, and diet) and neighborhood-level factors.

RESULTS

NSES was associated with obesity among African Americans, Latinos, and whites (p-trend ≤ 0.02), with twofold higher odds (adjusted odds ratios, 95% confidence intervals) for living in the lowest versus highest quintile among African American women (2.07, 1.62-2.65), white men (2.11, 1.29-3.44), and white women (2.50, 1.73-3.61). Lower density of businesses among African American and white women and lower traffic density among white men were also associated with obesity (p-trends ≤ 0.02).

CONCLUSIONS

Our study highlights differential impacts of neighborhood factors across racial/ethnic groups and establishes the foundation for multi-level studies of the neighborhood context and obesity-related cancers.

Repeated faecal occult blood testing is associated with decreased advanced colorectal cancer risk: A population-based study

OBJECTIVE

To evaluate the association between repeated faecal occult blood testing and advanced colorectal cancer risk at population level in Canada.

METHODS

A retrospective cohort study of all Ontario residents aged 56-74 diagnosed with colorectal cancer from 1 April 2007 to 31 March 2010, identified using health administrative data. The primary outcome was stage IV colorectal cancer, and primary exposure was faecal occult blood testing use within five years prior to colorectal cancer diagnosis. Patients were categorized into four mutually exclusive groups based on their exposure to faecal occult blood testing in the five years prior to colorectal cancer diagnosis: none, pre-diagnostic, repeated, and sporadic. Logistic regression was utilized to adjust for confounders.

RESULTS

Of 7753 patients (median age 66, interquartile range 61-70, 62% male) identified, 1694 (22%) presented with stage I, 2056 (27%) with stage II, 2428 (31%) with stage III, and 1575 (20%) with stage IV colorectal cancer. There were 4092 (53%) with no record of prior faecal occult blood testing, 1485 (19%) classified as pre-diagnostic, 1693 (22%) as sporadic, and 483 (6%) as repeated faecal occult blood testing. After adjusting for confounders, patients who had repeated faecal occult blood testing were significantly less likely to present with stage IV colorectal cancer at diagnosis (Odds ratio 0.46, 95% Confidence Interval 0.34-0.62) than those with no prior faecal occult blood testing.

CONCLUSIONS

Repeated faecal occult blood testing is associated with a decreased risk of advanced colorectal cancer. Our findings support the use of organized screening programmes that employ repeated faecal occult blood testing to improve colorectal cancer outcomes at population level.

Geographic variation and factors associated with colorectal cancer incidence in Manitoba

OBJECTIVES

Although individuals living in areas with lower household income have been shown to have higher rates of mortality from colorectal cancer (CRC), findings on the effect of income on CRC incidence in countries with universal health care have been inconsistent. There are limited data from Canada. We investigated the geographic variation and factors associated with CRC incidence in Manitoba, a central Canadian province.

METHODS

The Manitoba Cancer Registry and Manitoba Health population registry were used to determine age-sex-standardized CRC incidence rates between 1985 and 2012, which were geocoded to 498 small geographic areas (SGAs). The 2001 Canadian Census was used to determine the socio-demographic characteristics of the SGAs. Bayesian spatial Poisson modelling was used to assess geographic variation and factors associated with CRC incidence.

RESULTS

CRC incidence in SGAs ranged from 11 to 1026 per 100 000 population per year. Importantly, in the fully adjusted model there was no significant association between either average household income or proportion of recent immigrants in the SGAs and CRC incidence. Individuals living in urban areas had an overall lower CRC incidence (incidence rate ratio: 0.76; 95% credible interval: 0.58-0.98).

CONCLUSIONS

In a province with a universal health care system, our study suggests there are no disparities in CRC incidence by socio-economic level of the areas of residence. Rural areas should be a focus of CRC reduction initiatives in Manitoba. Similar analysis in other jurisdictions should be performed to evaluate the effect of the characteristics of SGAs on CRC incidence in different settings and target some of the efforts to reduce CRC burden.

Association between the neighborhood obesogenic environment and colorectal cancer risk in the Multiethnic Cohort

BACKGROUND

Information on the role of the neighborhood environment and colorectal cancer risk is limited. We investigated the association between a comprehensive suite of possible obesogenic neighborhood attributes (socioeconomic status, population density, restaurant and retail food environments, numbers of recreational facilities and businesses, commute patterns, traffic density, and street connectivity) and colorectal cancer risk in the Multiethnic Cohort Study.

METHODS

Among 81,197 eligible participants living in California (35,397 males and 45,800 females), 1973 incident cases (981 males and 992 females) of invasive colorectal cancer were identified between 1993 and 2010. Separately for males and females, multivariable Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for colorectal cancer risk overall and by racial/ethnic group (African American, Japanese American, Latino, white).

RESULTS

In males, higher traffic density was associated with an increased risk of colorectal cancer (HR=1.29, 95% CI: 1.03-1.61, p=0.03, for quintile 5 vs. quintile 1; p-trend=0.06). While this association may be due to chance, this pattern was seen (albeit non-statistically significant) in all racial/ethnic groups except whites. There were no other significant associations between other neighborhood obesogenic attributes and colorectal cancer risk.

CONCLUSION

Findings from our large racial/ethnically diverse cohort suggest neighborhood obesogenic characteristics are not strongly associated with the risk of colorectal cancer.

Microbiota, Inflammation and Colorectal Cancer

Colorectal cancer, the fourth leading cause of cancer-related death worldwide, is a multifactorial disease involving genetic, environmental and lifestyle risk factors. In addition, increased evidence has established a role for the intestinal microbiota in the development of colorectal cancer. Indeed, changes in the intestinal microbiota composition in colorectal cancer patients compared to control subjects have been reported. Several bacterial species have been shown to exhibit the pro-inflammatory and pro-carcinogenic properties, which could consequently have an impact on colorectal carcinogenesis. This review will summarize the current knowledge about the potential links between the intestinal microbiota and colorectal cancer, with a focus on the pro-carcinogenic properties of bacterial microbiota such as induction of inflammation, the biosynthesis of genotoxins that interfere with cell cycle regulation and the production of toxic metabolites. Finally, we will describe the potential therapeutic strategies based on intestinal microbiota manipulation for colorectal cancer treatment.

Disparities in the Age-Related Rates of Colorectal Cancer in the United States

The incidence of colorectal cancer (CRC) among Americans under the age of 50 years is increasing. The purpose of this study was to identify racial and socioeconomic disparities associated with this trend. The National Cancer Data Base was used to identify patients with CRC from 1998 to 2011. Patients were stratified by age (<50 versus >60 years), with ages 50 to 60 years omitted from the analysis to minimize overlapping trends between the two age groups. Relative frequencies (RFs) by year were plotted against demographic variables. Changes in RF over time and intervals from diagnosis to treatment (including surgery and chemotherapy) were compared. A total of 1,213,192 patients were studied; 885,510 patients with colon cancer and 327,682 with rectal or rectosigmoid cancer. Patients <50 years had higher RF for stage III/IV CRC compared with >60 years, with the highest rate of increase in stage III colon cancer (0.198% per year). Patients <50 years had higher RF for CRC if they were African-American or Hispanic. Hispanic patients <50 years had the highest rates of increase for both colon (RF = 0.300% per year) and rectal cancer (RF = 0.248% per year). Compared with race, other variables including education and income were not found to have as strong an association on age-related rates of CRC. No clinically significant differences were observed for time from diagnosis to treatment in either age group. Important racial disparities are associated with differences in age-related CRC rates, warranting further investigation to develop improved strategies for the earlier detection of CRC in these populations.

Neighborhood Socioeconomic Deprivation and Weight Change in a Large U.S. Cohort

INTRODUCTION

Both excessive weight gain and weight loss are important risk factors in the older population. Neighborhood environment may play an important role in weight change, but neighborhood effects on weight gain and weight loss have not been studied separately. This study examined the associations between neighborhood socioeconomic deprivation and excessive weight gain and weight loss.

METHODS

This analysis included 153,690 men and 105,179 women (aged 51-70 years). Baseline addresses were geocoded into geographic coordinates and linked to the 2000 U.S. Census at the Census tract level. Census variables were used to generate a socioeconomic deprivation index by principle component analysis. Excessive weight gain and loss were defined as gaining or losing >10% of baseline (1995-1996) body weight at follow-up (2004-2006). The analysis was performed in 2015.

RESULTS

More severe neighborhood socioeconomic deprivation was associated with higher risks of both excessive weight gain and weight loss after adjusting for individual indicators of SES, disease conditions, and lifestyle factors (Quintile 5 vs Quintile 1: weight gain, OR=1.36, 95% CI=1.28, 1.45 for men and OR=1.20, 95% CI=1.13, 1.27 for women; weight loss, OR=1.09, 95%% CI=1.02, 1.17 for men and OR=1.23, 95% CI=1.14, 1.32 for women). The findings were fairly consistent across subpopulations with different demographics and lifestyle factors.

CONCLUSIONS

Neighborhood socioeconomic deprivation predicts higher risk of excessive weight gain and weight loss.

Colorectal cancer statistics, 2017

Colorectal cancer (CRC) is one of the most common malignancies in the United States. Every 3 years, the American Cancer Society provides an update of CRC incidence, survival, and mortality rates and trends. Incidence data through 2013 were provided by the Surveillance, Epidemiology, and End Results program, the National Program of Cancer Registries, and the North American Association of Central Cancer Registries. Mortality data through 2014 were provided by the National Center for Health Statistics. CRC incidence rates are highest in Alaska Natives and blacks and lowest in Asian/Pacific Islanders, and they are 30% to 40% higher in men than in women. Recent temporal patterns are generally similar by race and sex, but differ by age. Between 2000 and 2013, incidence rates in adults aged ≥50 years declined by 32%, with the drop largest for distal tumors in people aged ≥65 years (incidence rate ratio [IRR], 0.50; 95% confidence interval [95% CI], 0.48-0.52) and smallest for rectal tumors in ages 50 to 64 years (male IRR, 0.91; 95% CI, 0.85-0.96; female IRR, 1.00; 95% CI, 0.93-1.08). Overall CRC incidence in individuals ages ≥50 years declined from 2009 to 2013 in every state except Arkansas, with the decrease exceeding 5% annually in 7 states; however, rectal tumor incidence in those ages 50 to 64 years was stable in most states. Among adults aged <50 years, CRC incidence rates increased by 22% from 2000 to 2013, driven solely by tumors in the distal colon (IRR, 1.24; 95% CI, 1.13-1.35) and rectum (IRR, 1.22; 95% CI, 1.13-1.31). Similar to incidence patterns, CRC death rates decreased by 34% among individuals aged ≥50 years during 2000 through 2014, but increased by 13% in those aged <50 years. Progress against CRC can be accelerated by increasing initiation of screening at age 50 years (average risk) or earlier (eg, family history of CRC/advanced adenomas) and eliminating disparities in high-quality treatment. In addition, research is needed to elucidate causes for increasing CRC in young adults. CA Cancer J Clin 2017. © 2017 American Cancer Society. CA Cancer J Clin 2017;67:177-193. © 2017 American Cancer Society.

Years of Life and Productivity Loss from Potentially Avoidable Colorectal Cancer Deaths in U.S. Counties with Lower Educational Attainment (2008-2012)

Background: Educational attainment (EA) is inversely associated with colorectal cancer risk. Colorectal cancer screening can save lives if precancerous polyps or early cancers are found and successfully treated. This study aims to estimate the potential productivity loss (PPL) and associated avoidable colorectal cancer-related deaths among screen-eligible adults residing in lower EA counties in the United States.Methods: Mortality and population data were used to examine colorectal cancer deaths (2008-2012) among adults aged 50 to 74 years in lower EA counties, and to estimate the expected number of deaths using the mortality experience from high EA counties. Excess deaths (observed-expected) were used to estimate potential years life lost, and the human capital method was used to estimate PPL in 2012 U.S. dollars.Results: County-level colorectal cancer death rates were inversely associated with county-level EA. Of the 100,857 colorectal cancer deaths in lower EA counties, we estimated that more than 21,000 (1 in 5) was potentially avoidable and resulted in nearly $2 billion annual productivity loss.Conclusions: County-level EA disparities contribute to a large number of potentially avoidable colorectal cancer-related deaths. Increased prevention and improved screening potentially could decrease deaths and help reduce the associated economic burden in lower EA communities. Increased screening could further reduce deaths in all EA groups.Impact: These results estimate the large economic impact of potentially avoidable colorectal cancer-related deaths in economically disadvantaged communities, as measured by lower EA. Cancer Epidemiol Biomarkers Prev; 26(5); 736-42. ©2016 AACR.

Mortality trends and risk of dying from colorectal cancer in the seven socioeconomic regions of Mexico, 2000-2012

BACKGROUND

In Mexico, there has been an upward trend in mortality rates from colorectal cancer (CRC) over the past three decades. This tumor is ranked among the ten most prevalent causes of morbidity from malignancies in Mexico.

AIMS

To determine the mortality trends by socioeconomic region and by state, and to establish the relative risk between both educational level and socioeconomic region with mortality from CRC within the time frame of 2000-2012.

MATERIALS AND METHODS

Records of mortality associated with colorectal cancer were obtained. Rates of mortality by state and by socioeconomic region were calculated, along with the strength of association (obtained through the Poisson regression) between both socioeconomic region and educational level and the mortality from CRC.

RESULTS

A total of 45,487 individuals died from CRC in Mexico from 2000 to 2012. Age-adjusted mortality rates per 100,000 inhabitants increased from 3.9 to 4.8. Baja California, Baja California Sur, and Sonora had the highest mortality from CRC. Individuals with no school or incomplete elementary school had a higher risk of dying from this cancer (RR of 3.57, 95% CI: 3.46-3.68). Region 7 had the strongest association with mortality from CRC (Mexico City: RR was 2.84, 95% CI: 2.39-3.37 [2000] and 3.32, 95% CI: 2.89-3.82 [2012]).

CONCLUSIONS

In Mexico, the age-adjusted mortality rates per 100,000 inhabitants that died from CRC increased from 3.9 to 4.8 in the study period, using the world population age distribution as the standard. Baja California, Baja California Sur, and Sonora had the highest mortality from CRC. Mexico City, which was socioeconomic region 7, had the strongest association with mortality from CRC.

Obstructive sleep apnea is associated with an increased risk of colorectal neoplasia

BACKGROUND AND AIMS

A recent meta-analysis showed that obstructive sleep apnea (OSA) is associated with a higher prevalence of cancer and cancer-related mortality; however, little information is available on the association between OSA and colorectal neoplasia.

METHODS

We identified consecutive patients who underwent overnight polysomnography (PSG) and subsequent colonoscopy. We compared the prevalence of colorectal neoplasia between patients with or without OSA according to the results of PSG. For each patient with OSA, 1 or 2 controls matched for age (±5 years), sex, body mass index (BMI), and smoking who had undergone first-time screening colonoscopy were selected.

RESULTS

Of the 163 patients, 111 patients were diagnosed with OSA and 52 patients were within the normal range of the Apnea-Hypopnea Index. Of the 111 patients with OSA, 18 patients (16.2%) had advanced colorectal neoplasia, including 4 (3.6%) colorectal cancers. In the multivariate analyses, OSA was associated with an increased risk of advanced colorectal neoplasia after adjusting for factors including age and sex (mild: odds ratio [OR], 14.09; 95% confidence interval [CI], 1.55-127.83; P = .019; moderate or severe: OR, 14.12; 95% CI, 1.52-131.25; P = .020). Our case-control study revealed that the odds of detecting advanced colorectal neoplasia among patients with OSA were approximately 3.03 times greater than in the controls matched for age, sex, BMI, and smoking (OR, 3.03; 95% CI, 1.44-6.34; P = .002).

CONCLUSION

Physicians should be aware of the association between OSA and the development of colorectal neoplasia and explain the need for colonoscopy to patients with OSA.

Colorectal cancer-global burden, trends, and geographical variations

BACKGROUND

The aim of this study is to describe the trends and variations in the global burden of colorectal cancer (CRC).

METHODS

Data (2012-2030) relating to CRC was extracted from GLOBOCAN 2012 database and analyzed.

RESULTS

The results of our study demonstrate a rising global burden of colorectal cancer which persists until the year 2035 and likely beyond. The rise in the global burden is not uniform with significant variations influenced by geographic location, socio-economic status, age, and gender. Although the EURO region has the highest burden, Asia as a continent continues to bear the heaviest brunt of the disease. Although the burden of disease is higher in more developed regions, mortality is considerably higher in less developed regions and this gap widens over the next two decades. The disease predominantly affects the male gender across all regions of the world. Age has a complex relation with the burden of CRC and is affected by the cross-influences relating to socio-economic status.

CONCLUSIONS

The results of our study demonstrate a rising global burden of CRC with some unique variations. Knowledge of this data can increase awareness and help strategic targeting of efforts and resources.

Exercise and Sports Medicine Issues in Underserved Populations

Primary care providers can make a strong argument for exercise promotion in underserved communities. The benefits are vitally important in adolescent physical, cognitive, and psychological development as well as in adult disease prevention and treatment. In counseling such patients, we should take into account a patient's readiness for change and the barriers to exercise.