Increasing incidence of colon and rectal cancer among Hispanics and American Indians in New Mexico (United States), 1969-94

Effectiveness of Biologic Agents Among Hispanic Patients With Metastatic Colorectal Cancer

BACKGROUND

Randomized clinical trials have defined the survival advantage with the addition of biologic drugs to chemotherapy in patients with metastatic colorectal cancer (mCRC). Under representation of Hispanics contributes to poorly defined outcomes in this group. We aim to determine whether the real-world benefit of biologics extends to Hispanics using a comparative effectiveness research approach.

METHODS

This retrospective cohort study included all treatment centers contributing to SEER registry with available claims in the SEER-Medicare linked database (2001-2011) and 2 hospitals (2004-2016) catering to minorities. Metastatic CRC patients were classified as receiving chemotherapy or biochemotherapy (CT plus biologics; if initiated within 3 months of chemotherapy). The primary outcome was overall survival (OS) among the Hispanic patients calculated from time of administration of first dose of chemotherapy to death or last follow-up. A weighted Cox regression model was used to assess differences in survival.

RESULTS

We identified 182 Hispanic patients with mCRC from the Patient Entitlement and Diagnosis Summary (PEDSF) file (n = 101) and hospital database (n = 81). Overall, 52% were women and 72% received biologics. The median OS was 11.3 and 17.0 months in chemotherapy and biochemotherapy group, respectively. Biochemotherapy offered a survival benefit compared with chemotherapy alone, with an average hazard rate reduction of 39% (95% CI 6%-60%, p = .0236) using inverse probability of treatment weighting (IPTW) based analysis.

CONCLUSION

In this cohort of Hispanic patients with mCRC, biochemotherapy was associated with longer survival. Clinicians may offer biochemotherapy therapy to all patients regardless of race/ethnicity to maximize clinical benefit.

Colorectal Cancer Survival Trends in the United States From 1992 to 2018 Differ Among Persons From Five Racial and Ethnic Groups According to Stage at Diagnosis: A SEER-Based Study

Introduction

Survival following colorectal cancer (CRC) has improved in the US since 1975, but there is limited information on stage-specific survival trends among racial and ethnic subgroups.

Objectives

The purpose of this study was to estimate and compare trends in 1- and 5-year CRC cause-specific survival in the United States by both stage and race/ethnicity.

Methods

We performed a retrospective cohort study of individuals diagnosed with CRC using the 1992-2018 Surveillance, Epidemiology and End Results (SEER) database. We estimated and compared time trends in 1- and 5-year survival for CRC stage by race/ethnicity.

Results

Data from 399 220 individuals diagnosed with CRC were available. There were significant differences in stage-specific 1-year survival trends by race and ethnicity. Differences were most notable for distant stage CRC: survival probabilities increased most consistently for non-Hispanic American Indian/Alaska Native (AIAN) and Black (NHB) persons, but their trend lines were lower than those of Hispanic, and non-Hispanic Asian/Pacific Islander (API) and White (NHW) persons, whose initially greater gains appear to be slowing. Although the data do not support significant racial/ethnic differences in 5-year CRC survival trends by stage, AIAN and NHB persons have the lowest average survival probabilities for multiple CRC stages, and no racial/ethnic group has 5-year survival probabilities above 20% for distant-stage CRC.

Conclusion

Although there has been an overall improvement in adjusted CRC-specific survival probabilities since 1992, AIAN and NHB persons continue to experience worse prognosis than those of other races/ethnicities. This highlights the importance of reinvigorating efforts to understand the causes of mortality in CRC, including those which may differ according to an individual’s race or ethnicity.

Ethnic disparities in renal cell carcinoma: An analysis of Hispanic patients in a single-payer healthcare system

OBJECTIVE

To investigate differences between Hispanics and non-Hispanic whites diagnosed with and treated for renal cell carcinoma in an equal access healthcare system.

METHODS

We carried out a retrospective cohort study within the Kaiser Permanente healthcare system using records from renal cell carcinoma cases. Ethnicity was identified as Hispanic or non-Hispanic whites. Patient characteristics, comorbidities, tumor characteristics and treatment were compared. Overall and disease-specific survival was calculated, and a Cox proportion hazard model estimated the association of ethnicity and survival.

RESULTS

A total of 2577 patients (2152 non-Hispanic whites, 425 Hispanic) were evaluated. Hispanics were diagnosed at a younger age (59.6 years vs 65.3 years). Clear cell renal cell carcinoma was more prevalent, whereas papillary renal cell carcinoma was less common among Hispanics. Hispanics had a lower American Joint Committee on Cancer stage (I/II vs III/IV) than non-Hispanic whites (67.4% vs 62.2%). Hispanics were found to have a greater frequency of comorbidities, such as chronic kidney disease and diabetes, but were more likely to receive surgery. The presence of metastases, nodal involvement, increased tumor size, non-surgical management, increasing age and Hispanic ethnicity were independent predictors of worse cancer-specific outcome.

CONCLUSIONS

Within an equal access healthcare system, Hispanics seem to be diagnosed at younger ages, to have greater comorbidities and to present more frequently with clear cell renal cell carcinoma compared with non-Hispanic white patients. Despite lower stage and greater receipt of surgery, Hispanic ethnicity seems to be an independent predictor of mortality. Further work is necessary to confirm these findings.

Adenoma Prevalence and Distribution Among US Latino Subgroups Undergoing Screening Colonoscopy

BACKGROUND

Colorectal cancer (CRC) is the second leading malignancy diagnosed among US Latinos. Latinos in the USA represent a heterogeneous amalgam of subgroups varying in genetic background, culture, and socioeconomic status. Little is known about the frequency of CRC precursor lesions found at screening colonoscopy among Latino subgroups.

AIM

The aim was to determine the prevalence and distribution of histologically confirmed adenomas found at screening colonoscopy among average-risk, asymptomatic US Latinos according to their subgroup and socio-demographic background.

METHODS

Cross-sectional analysis of pathological findings resulting from screening colonoscopy among average-risk, asymptomatic US Latinos aged ≥50 in two prospective randomized controlled trials at an academic medical center.

RESULTS

Among the 561 Latinos who completed screening colonoscopy, the two largest subgroups were Puerto Ricans and Dominicans. The findings among both subgroups were: adenomas 30.6%, proximal adenomas 23.5%, advanced adenomas 12.0%, and proximal advanced adenomas 8.9%. These rates are at least as high as those found at screening colonoscopy among US whites. While Puerto Ricans were more likely than Dominicans to be born in the USA, speak English, be acculturated, have a smoking history, and be obese, there were no significant differences in adenoma rates between these subgroups.

CONCLUSIONS

The prevalence of adenomas, advanced adenomas, and proximal neoplasia was high among both subgroups. These findings have implications for CRC screening and surveillance among the increasingly growing Latino population in the USA.

Cap-Assisted Colonoscopy Increases Detection of Advanced Adenomas and Polyps

BACKGROUND

Cap-assisted colonoscopy (CAC) has been reported to increase the adenoma detection rate (ADR) in Asian population. However, CAC trials in non-Asian population have had conflicting results. Studies in North America have shown an improvement in ADRs with the use of CAC, but it mainly included white and African American patients. Given the lack of prospective studies of CAC in Hispanics, we conducted this randomized controlled trial.

MATERIALS AND METHODS

This is a randomized controlled trial comparing CAC with standard colonoscopy (SC) in patients undergoing screening or surveillance colonoscopy. Our primary outcome was the ADR. Secondary outcomes were polyp detection rate, mean polyp and ADR, advanced ADR (AADR) and detection rates based on polyp morphology and location.

RESULTS

A total of 440 patients were included in the study (88.5% Hispanic). Cecal and terminal ileum intubation rates were similar in both groups (CAC: 97% and 86% versus SC: 99% and 81%, respectively). CAC did not improve ADR in comparison with SC (0.65 versus 0.52; P = 0.079); however, CAC had a higher AADR in comparison with SC (9.9% versus 4.6%; P = 0.049). CAC detected significantly more pedunculated polyps as compared with flat and sessile polyps (P = 0.011). Complication rates were similar in the CAC and SC groups (0.9% versus 0%).

CONCLUSIONS

In a predominantly Hispanic population, no difference was seen in the mean ADR with the use of CAC. However, CAC, when compared with SC, resulted in an increased AADR and mean polyp detection rate.

The influence of health disparities on targeting cancer prevention efforts

Despite the advances in cancer medicine and the resultant 20% decline in cancer death rates for Americans since 1991, there remain distinct cancer health disparities among African Americans, Hispanics, Native Americans, and the those living in poverty. Minorities and the poor continue to bear the disproportionate burden of cancer, especially in terms of stage at diagnosis, incidence, and mortality. Cancer health disparities are persistent reminders that state-of-the-art cancer prevention, diagnosis, and treatment are not equally effective for and accessible to all Americans. The cancer prevention model must take into account the phenotype of accelerated aging associated with health disparities as well as the important interplay of biological and sociocultural factors that lead to disparate health outcomes. The building blocks of this prevention model will include interdisciplinary prevention modalities that encourage partnerships across medical and nonmedical entities, community-based participatory research, development of ethnically and racially diverse research cohorts, and full actualization of the prevention benefits outlined in the 2010 Patient Protection and Affordable Care Act. However, the most essential facet should be a thoughtful integration of cancer prevention and screening into prevention, screening, and disease management activities for hypertension and diabetes mellitus because these chronic medical illnesses have a substantial prevalence in populations at risk for cancer disparities and cause considerable comorbidity and likely complicate effective treatment and contribute to disproportionate cancer death rates.

Colorectal cancer incidence and mortality disparities in new Mexico

Background. Previous analyses indicated that New Mexican Hispanics and American Indians (AI) did not experience the declining colorectal cancer (CRC) incidence and mortality rates observed among non-Hispanic whites (NHW). We evaluated more recent data to determine whether racial/ethnic differences persisted. Methods. We used New Mexico Surveillance Epidemiology and End Results data from 1995 to 2009 to calculate age-specific incidence rates and age-adjusted incidence rates overall and by tumor stage. We calculated mortality rates using National Center for Health Statistics' data. We used joinpoint regression to determine annual percentage change (APC) in age-adjusted incidence rates. Analyses were stratified by race/ethnicity and gender. Results. Incidence rates continued declining in NHW (APC -1.45% men, -1.06% women), while nonsignificantly increasing for AI (1.67% men, 1.26% women) and Hispanic women (0.24%). The APC initially increased in Hispanic men through 2001 (3.33%, P = 0.06), before declining (-3.10%, P = 0.003). Incidence rates declined in NHW and Hispanics aged 75 and older. Incidence rates for distant-stage cancer remained stable for all groups. Mortality rates declined significantly in NHW and Hispanics. Conclusions. Racial/ethnic disparities in CRC persist in New Mexico. Incidence differences could be related to risk factors or access to screening; mortality differences could be due to patterns of care for screening or treatment.

Media complementarity and health information seeking in Puerto Rico

This investigation incorporates the Orientation1-Stimulus-Orientation2-Response model on the antecedents and outcomes of individual-level complementarity of media use in health information seeking. A secondary analysis of the Health Information National Trends Survey Puerto Rico data suggests that education and gender were positively associated with individual-level media complementarity of health information seeking, which, in turn, was positively associated with awareness of health concepts and organizations, and this awareness was positively associated with a specific health behavior: fruit and vegetable consumption. This study extends the research in media complementarity and health information use; it provides an integrative social psychological model empirically supported by the Health Information National Trends Survey Puerto Rico data.

Comparison of adenoma detection rate in Hispanics and whites undergoing first screening colonoscopy: a retrospective chart review

BACKGROUND

Current guidelines recommend screening colonoscopy beginning at age 50 in the average-risk population. Race has been shown to influence the risk of colorectal cancer, thus leading to the recommendation of initiating screening in blacks at the age of 45. Few data exist on the prevalence of colon polyps among U.S. Hispanics.

OBJECTIVES

To compare the adenoma detection rate (ADR) between Hispanics and whites undergoing a first screening colonoscopy at our referral center.

DESIGN

Observational study.

SETTING

Single endoscopy unit, tertiary care teaching hospital.

PATIENTS

Patients 50 years of age or older undergoing their first screening colonoscopy whose race was determined as white or Hispanic from June 2007 to August 2010.

MAIN OUTCOME MEASUREMENT

ADR by race.

RESULTS

There was no statistically significant difference in the ADR among Hispanics and whites (45% and 48%, respectively; P = .2). No difference was found when comparing the ADR in Hispanic and white males (50% and 55%, respectively; P = .2), Hispanic and white females (40% in both groups), or in the 50- to 59-year-old subgroup (42% in Hispanics, 45% in whites, P = .4). There was no difference in the prevalence of advanced adenomas (3% in Hispanics, 4% in whites, P = .3). The prevalence of proximal polyps in Hispanics and whites was similar (18% and 19%, respectively, P = .8).

LIMITATIONS

Retrospective design, self-identification of race/ethnicity, underrepresentation of certain Hispanic subgroups.

CONCLUSIONS

We found a similar ADR among Hispanics and whites undergoing their first screening colonoscopy. These findings have important implications for colorectal cancer screening recommendations, suggesting that the current guidelines are appropriate for Hispanics.

Trends in colorectal cancer among hispanics by stage and subsite location: 1989-2006

OBJECTIVES:

Hispanic colorectal cancer (CRC) rates historically have been lower than for non-Hispanic Whites in the United States and in Florida. The aim of this study is to understand CRC trends in Florida Hispanics and non-Hispanic Whites.

METHODS:

Using a cross-sectional study design, all invasive CRCs diagnosed among Florida residents between 1989 and 2006 were accessed from the Florida Cancer Data System (FCDS). These cases were analyzed by Hispanic and non-Hispanic White ethnic identification. The Hispanic Origin Identification Algorithm was applied to the FCDS data to identify Hispanic subjects. Primary cancer site and histology data were organized according to SEER (Surveillance Epidemiology and End Results) categories. Joinpoint regression was used to generate incidence trends by stage and subsite location.

RESULTS:

Rates of CRC incidence were higher for Florida Hispanics compared with non-Hispanic Whites since the mid 1990s. There was a consistent significant increase in the incidence of distant stage CRC in Hispanics (annual percent change (APC) of 1.26 and 0.90 in males and females), whereas rates in non-Hispanics decreased significantly during the same time period (APC −1.36 and −1.28, respectively). Similar trends were found in distant-stage right-sided CRC. Among right-sided CRCs, local stage incidence rate increased for both non-Hispanic Whites and Hispanics, whereas the incidence rate for regional stage decreased for both racial/ethnic groups.

CONCLUSIONS:

Trends for distant-stage CRC are increasing among Florida Hispanics. This is a particular public health concern given that CRC is a cancer for which screening modalities exist and could imply a concomitant increase in CRC-related mortality among Florida Hispanics. Lower rates of CRC screening in Hispanics are documented at the state level, relative to non-Hispanic Whites. Screening programs targeting the Florida Hispanic population are warranted.

Cancer statistics for Hispanics/Latinos, 2012

Hispanics/Latinos are the largest and fastest growing major demographic group in the United States, accounting for 16.3% (50.5 million/310 million) of the US population in 2010. In this article, the American Cancer Society updates a previous report on cancer statistics for Hispanics using incidence data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. In 2012, an estimated 112,800 new cases of cancer will be diagnosed and 33,200 cancer deaths will occur among Hispanics. In 2009, the most recent year for which actual data are available, cancer surpassed heart disease as the leading cause of death among Hispanics. Among US Hispanics during the past 10 years of available data (2000-2009), cancer incidence rates declined by 1.7% per year among men and 0.3% per year among women, while cancer death rates declined by 2.3% per year in men and 1.4% per year in women. Hispanics have lower incidence and death rates than non-Hispanic whites for all cancers combined and for the 4 most common cancers (breast, prostate, lung and bronchus, and colorectum). However, Hispanics have higher incidence and mortality rates for cancers of the stomach, liver, uterine cervix, and gallbladder, reflecting greater exposure to cancer-causing infectious agents, lower rates of screening for cervical cancer, differences in lifestyle and dietary patterns, and possibly genetic factors. Strategies for reducing cancer risk among Hispanics include increasing utilization of screening and available vaccines, as well as implementing effective interventions to reduce obesity, alcohol consumption, and tobacco use.

Expressions of machismo in colorectal cancer screening among New Mexico Hispanic subpopulations

Although national colorectal cancer (CRC) incidence rates have steadily decreased, the rate for New Mexico Hispanics has been increasing, and screening rates are low. We conducted an exploratory qualitative study to determine barriers to CRC screening for New Mexico Hispanics. We found that machismo served as a dynamic influence on men's health-seeking behaviors; however, it was conceptualized differently by two distinct Hispanic subpopulations, and therefore appeared to play a different role in shaping their screening attitudes and behaviors. Machismo emerged as more of an influence for Mexican men, who expressed concern over colonoscopies being potentially transformative and/or stigmatizing, but was not as salient for Hispanos, who viewed the colonoscopy as "strictly medical," and were more concerned with discomfort and pain. Findings from the study highlight the importance of identifying varying characteristics among subpopulations to better understand screening barriers and provide optimal CRC screening counseling in primary care settings.

The relationship between distal and proximal colonic neoplasia: a meta-analysis

OBJECTIVES

To investigate the association between proximal colonic neoplasia and distal lesions as a function of the lesion type. The extent to which health, demographic, and study characteristics moderate this association was also examined.

DATA SOURCES

Google Scholar, Web of Science, Scopus, and PubMed.

STUDY ELIGIBILITY CRITERIA

Studies allowing the calculation of OR of proximal neoplasia (PN) and proximal advanced neoplasia (PAN) for distal hyperplastic polyps (HP), nonadvanced adenomas (NAA), adenomas (AD), and advanced neoplasia (AN); also, studies for which the proportions of subjects with isolated (i.e., not accompanied by distal lesions) PN (IPN) and PAN (IPAN) over the total number of subjects with PN or PAN could be calculated.

STUDY APPRAISAL AND SYNTHESIS METHODS

Thirty-two studies were included for calculating OR between proximal neoplasia and distal lesions and 40 studies for proportions of IPN and IPAN. Subgroup analyses were conducted for presence of symptoms, prevalence of PN and PAN, age, proportion of males, geographic region, study design, and demarcation point.

RESULTS

The association between distal lesions and proximal neoplasia increased with the severity of the distal lesions. Odds of PN were higher in subjects with HP compared to subjects with a normal distal colon. Odds of PN and PAN were higher in subjects with NAA, AD, and AN than in subjects with a normal distal colon. PAN were more strongly associated with distal lesions in asymptomatic populations, in young populations, and in populations with a low prevalence of PAN. In approximately 60% of the subjects with PN and PAN, these neoplasia were isolated.

LIMITATIONS

The present results may be affected by publication bias and dichotomization in the subgroup analyses. Limitations related to the individual studies include self-selection, lesion misclassification and misses, and technological advances leading to changes in the detection of lesions during the time span of the included studies.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

All types of distal lesions are predictive of PN. All types of distal neoplasia are predictive of PAN. The association between distal lesions and proximal neoplasia increases with the severity of the distal lesion. The association between distal lesions and proximal advanced neoplasia is stronger in low-risk groups as compared to high-risk groups.

A public-health perspective on screening colonoscopy

Colorectal cancer is an important global health problem. Randomized trials have shown that screening programs can reduce both colorectal cancer incidence and mortality, and guidelines strongly support screening. Nevertheless, screening rates are relatively low and concerted efforts are being made to increase screening uptake. Many guidelines and practitioners have come to view colonoscopy as the optimal screening strategy. Colonoscopy provides both a gold-standard diagnostic test and, with polypectomy, a therapeutic intervention that can prevent cancer. However, from a public-health perspective, emphasizing colonoscopy is problematic. The efficacy of colonoscopy has not been supported with randomized trial data, accuracy is imperfect, procedural quality is variable, complications are not uncommon, endoscopic capacity is limited, procedure costs are high, and many patients prefer alternative tests. Successful screening programs will need to provide a range of screening modalities and ensure that endoscopic resources are used efficiently.

Racial differences in colorectal cancer incidence and mortality in the Women's Health Initiative

BACKGROUND

Colorectal cancer (CRC) incidence and mortality rates are higher in African-Americans as compared with other racial/ethnic groups. The women's health initiative (WHI) study sample was used to determine whether differences in CRC risk factors explain racial/ethnic differences in incidence and mortality.

METHODS

The WHI is a longitudinal study of postmenopausal women recruited from 40 centers. Baseline questionnaires were used to collect sociodemographic and health status information. All CRC diagnoses were centrally adjudicated. Cox regression models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for invasive CRC by race/ethnicity.

RESULTS

The study sample included 131,481 (83.7%) White, 14,323 (9.1%) African-American, 6,362 (4.1%) Hispanic, 694 (0.4%) Native American and 4,148 (2.6%) Asian/Pacific Islanders. After a mean follow-up of 10.8 years (SD 2.9), CRC incidence was the highest in African-Americans (annualized rate = 0.14%), followed by Whites and Native Americans (0.12% each), Asian/Pacific Islanders (0.10%), and Hispanics (0.08%). After adjustment for age and trial assignment, Hispanics had a lower risk compared with Whites, HR 0.73 (95% CI: 0.54-0.97) (P = 0.03), and African-Americans had a marginally greater risk, HR 1.16 (95% CI: 0.99-1.34), P = 0.06. Multivariable adjustment attenuated the difference in incidence between African-Americans and Whites (HR 0.99, 95% CI: 0.82-1.20), while strengthening the lower HR for Hispanics (HR 0.68, 95% CI: 0.48-0.97).

CONCLUSIONS

African-American/White differences in CRC risk are likely due to sociodemographic/cultural factors other than race.

IMPACT

A number of modifiable exposures could be a focus for reducing CRC risk in African-Americans.

Ethnic issues in endoscopy

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few or no data exist from well-designed prospective trials, emphasis is placed on results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the quality of the supporting evidence (Table 1). The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as "we suggest," whereas stronger recommendations are typically stated as "we recommend." This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from this guideline.

Regional differences in colorectal cancer incidence, stage, and subsite among American Indians and Alaska Natives, 1999-2004

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality for American Indians and Alaska Natives (AI/ANs), but misclassification of race causes underestimates of disease burden.

METHODS

The authors compared regional differences in CRC incidence, stage at diagnosis, and anatomic distribution between AI/ANs and non-Hispanic whites (NHWs). To reduce misclassification, data from the National Program of Cancer Registries; the Surveillance, Epidemiology, and End Results Program; and the Indian Health Service (IHS) were linked. The analysis was limited to the 56% of AI/AN who live in IHS Contract Health Service Delivery Areas.

RESULTS

From 1999 to 2004, the overall incidence rate (per 100,000 persons per year) of CRC was 9% lower in the AI/AN population (46.3) than in the NHW population (50.8). However, AI/AN CRC incidence rates varied nearly 5-fold regionally, from 21 in the Southwest to 102.6 in Alaska. Compared with NHW rates, AI/AN rates were significantly higher in Alaska (rate ratio [RR], 2.03), the Northern Plains (RR, 1.39), and the Southern Plains (RR, 1.16) but were lower in the Pacific Coast (RR, 0.80), the East (RR, 0.65), and the Southwest (RR, 0.45). AI/ANs were diagnosed more often with advanced CRC than with localized CRC (RR, 1.92) compared with NHWs (RR, 1.48). Females more often had proximal CRC among both the AI/AN population (females, 40.1%; males, 33.5%) and the NHW population (females, 50.1%; males, 40.3%), although AI/ANs had a higher proportion of distal cancers overall.

CONCLUSIONS

CRC incidence rates in AI/AN populations varied dramatically between regions. Efforts are needed to make CRC screening a priority, overcome barriers to endoscopic screening, and to engage AI/AN communities in culturally appropriate ways to participate in prevention and early detection programs.

Cancer in American Indian and Alaska Native young adults (ages 20-44 years): US, 1999-2004

BACKGROUND

An examination of cancer incidence patterns in American Indians and Alaska Native (AI/AN) young adults may provide insight into their present and future cancer burden.

METHODS

To reduce racial misclassification, incidence data were linked with the Indian Health Service (IHS) patient services database. Age-adjusted cancer incidence rates per 100,000 (AAR) and corresponding rate ratios (RR) for young adults (ages 20-44 years) were compared across IHS regions and for selected cancers within Contract Health Service Delivery Area counties by race (AI/AN vs non-Hispanic whites [NHW]) and sex.

RESULTS

The all-sites cancer incidence rate was lower for AI/ANs (AAR of 83.8) than for NHWs (AAR of 111.2) (RR of 0.75) but varied by IHS regions. Among the leading cancers in AI/AN females the risk was elevated for stomach (RR of 3.22), colorectal (RR of 1.30), uterine (RR of 1.61), and kidney (RR of 1.39) cancers and was lower for breast (RR of 0.70) and thyroid (RR of 0.71) cancers. Among AI/AN young adult males the risk was elevated for stomach (RR of 2.62), liver (RR of 1.89), and kidney (RR of 1.59) cancers and lower for testicular germ cell cancer (RR of 0.64) and lymphoma (RR of 0.60). The risk for these and other cancers varied across IHS regions.

CONCLUSIONS

Many of the cancer patterns that characterize the AI/AN population overall are apparent among young adults. Compared with NHW young adults, the overall cancer burden among AI/AN young adults was lower but varied for selected cancers and across IHS regions. Cancer control and research strategies are needed to address the unique genetic, social, cultural, and lifestyle aspects of AI/AN young adults.

Investigating Hispanic/Latino perceptions about colorectal cancer screening: a community-based approach to effective message design

OBJECTIVE

The Hispanic/Latino population has been documented as having the lowest colorectal cancer (CRC) screening rates in the United States, putting this group at-risk for late-stage presentation of disease. We assessed knowledge, attitudes, and behavior regarding CRC screening to inform the development of messages that promote screening among Hispanic/Latino patients.

METHODS

In-person structured interviews with Spanish-speaking adults age 50-80 at two clinics and a senior center in a Hispanic/Latino community (N=234).

RESULTS

Most (67.1%) participants had no more than an eighth-grade education and 63.3% reported their reading ability as less than "very good." Only 18.4% of participants correctly identified the colon on a diagram; 19.2% correctly described at least one aspect of a polyp. Less than half of the participants perceived themselves as at-risk for CRC, and less than one-third knew about any of the standard screening tests. After hearing descriptions of the screening tests, participants perceived stool cards as easier, safer, less painful, less embarrassing, and less scary than endoscopy (p<.001). Approximately two-thirds of unscreened patients said that screening had never been mentioned or suggested to them; about one-quarter said they did not get screened because they felt fine or were not worried. Over 96% of participants said they would get screened if a doctor suggested it.

CONCLUSION

Assessing knowledge, attitudes, beliefs, and experiences in the community of interest is a promising approach for developing effective targeted health messages.

PRACTICE IMPLICATIONS

Messages to increase CRC screening knowledge and behavior in the Hispanic/Latino community should address risk factors, identify relevant anatomy, explain polyps and their asymptomatic presentation, and clearly describe options.

Unexplained inversion of the incidence ratio of colon and rectal cancer among men in East Germany. A time trend analysis including 147,790 cases

INTRODUCTION

The incidence rate ratio of colon to rectal cancer is usually about 2:1. It has been observed for a while that the incidence of colon cancer among men (as opposed to women) in the Former German Democratic Republic (GDR) is lower than the rate of rectal cancer. Detailed analyses of this phenomenon have not been done so far. The aim was to give insights in this observation by detailed incidence and mortality analyses and to explore the worldwide ratio of colon and rectal cancers based on population-based cancer registry data.

METHODS

We analyzed age-standardized incidence and mortality data of colorectal cancers in East Germany (1961-1989 and 1996-2002; mortality 1980-2002), West Germany, Saarland (1970-2002) and all over the world (1978-82 up to 1993-97).

RESULTS

With the incidence increase of colorectal cancers in the GDR, the ratio of colon to rectal cancer incidence became larger and surpassed the reference value (ratio = 1) during the time of the reunification. Also the mortality data revealed a similar pattern. Estimated annual percentage increases of colon subsite incidences tended to be higher within the distal colon as compared to the proximal colon

CONCLUSIONS

Our analyses of international cancer registries over a period of 20 years show that the colon-rectum cancer ratio is positively associated with the overall incidence of colorectal cancer with a stronger association among women than men. Non-causal factors such as underdetection or registration artefacts are unlikely to explain the unusual colon/rectal rate ratio among men. A gradual decrease of the job-related physical activity among men may have contributed to the findings.

Use of the spatial scan statistic to identify geographic variations in late stage colorectal cancer in California (United States)

OBJECTIVES

To identify geographic variations in colorectal cancer by stage at diagnosis in California using a descriptive analysis coupled with a spatial analysis and to discuss methodological considerations concerning the spatial statistical method.

METHODS

We analyzed 59,076 colorectal cancer cases diagnosed in California from 1996 to 2000 by logistic regression and by a spatial scan statistic to identify areas with a higher and lower relative risk of late-stage colorectal cancer.

RESULTS

In California, 57% of overall cases of colorectal cancer were diagnosed at a late stage. Californians diagnosed with late-stage colorectal cancer were more likely to be Hispanic and living in areas of lower socioeconomic status. The spatial scan identified two areas where the observed number of late-stage cancer was different than the number expected from the distribution in the rest of the state.

CONCLUSIONS

Spatial scan analyses can complement descriptive statistics, but results must be interpreted with consideration of factors that affect the ability to detect meaningful differences such as the number of events observed, accuracy in geocoding rural versus urban addresses, and the difficulty of adjusting for covariates.

Celebremos la salud! a community randomized trial of cancer prevention (United States)

BACKGROUND

Compared to non-Hispanic whites, Hispanics in the United States are at higher risk for certain types of cancer.

METHODS

In a randomized controlled trial of 20 communities, we examined whether a comprehensive intervention influenced cancer screening behaviors and lifestyle practices in rural communities in Eastern Washington State. Cross-sectional surveys at baseline and post-intervention included interviews with a random sample of approximately 100 households per community. The interview included questions on ever use and recent use of Pap test, mammogram, and fecal occult blood test (FOBT) and sigmoidoscopy/colonoscopy, fruit and vegetable consumption and smoking practices.

RESULTS

We found few significant changes in use of screening services for cervical (Pap test), breast (mammogram) or colorectal cancer (fecal occult blood test (FOBT) or sigmoidoscopy/colonoscopy) between intervention and control communities. We found no significant differences in fruit and vegetable consumption nor in smoking prevalence between the two groups. We found more awareness of and participation in intervention activities in the treatment communities than the control communities.

CONCLUSIONS

Our null findings might be attributable to the low dose of the intervention, a cohort effect, or contamination of the effect in non-intervention communities. Further research to identify effective strategies to improve cancer prevention lifestyle behaviors and screening practices are needed.

Secular changes in colorectal cancer incidence by subsite, stage at diagnosis, and race/ethnicity, 1992-2001

BACKGROUND

Cancers of the colon and rectum are the third most common malignancy among males and females in the United States, although incidence and mortality have declined in recent years. We evaluated recent trends in colorectal cancer incidence in the United States by subsite and stage at diagnosis.

METHODS

Data for this analysis included all cases of colorectal cancer diagnosed between 1992 and 2001 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program. Incidence rates were stratified by gender, race/ethnicity, anatomic subsite, stage at diagnosis, and SEER registry. Trends in incidence over time were measured using the estimated annual percentage change.

RESULTS

The study population included 95,539 males and 93,329 females with colorectal cancer. For all 12 SEER registries combined, incidence declined between 1992 and 2001 by 1.2% per year among males and 0.7% per year (not statistically significant) among females. Rates for non-Hispanic whites declined by an average of 1.3% per year for males and 0.6% per year for females. Overall rates for black, Asian/Pacific Islander, and Hispanic males and females did not change significantly except for a 0.8% decline among Asian/Pacific Islander males. Declines in rates among males and females were most pronounced for tumors of the sigmoid colon.

CONCLUSIONS

Colorectal cancer rates decreased in the United States during the 1990s. Decreases were most pronounced among males, among non-Hispanic whites, and for tumors of the sigmoid colon. These reductions are probably dueto the increased use of screening.

Colorectal Cancer in Hispanics

BACKGROUND

While colorectal cancer (CRC) incidence and mortality rates have declined slightly over the past decade, there remain marked differences by ethnicity. Our aim was to investigate ethnic differences in occurrence, clinical presentation and outcome of CRC at a tertiary university center that serves a predominantly Hispanic population.

METHODS

Prospectively collected data from the tumor registry on patients diagnosed with colorectal cancer from 1985 through 2001 was examined. Age at diagnosis, mode of presentation, sex, tumor location, ethnicity, TNM stage, and survivals were assessed and ethnic differences were sought.

RESULTS

Records from 453 patients with CRC were reviewed. There were 296 (65%) patients that were Hispanics, 112 (25%) non-Hispanic Whites, 37 (8%) African Americans, and 8 (2%) of other or unknown ethnicity. Compared with non-Hispanic Whites, Hispanics presented at a younger age (58.5 +/- 14 versus 53.6 +/- 12.73, respectively; P < 0.01), with a significantly greater incidence of stage IV disease (19% versus 32%, respectively; P = 0.02). They had significantly poorer age-adjusted survival (median survival of 92 months for <55 years and 77 months for >55 years versus 48 months for <55 years and 48 months for >55 years, respectively; adjusted log rank P = 0.045). There were no differences in tumor location, mode of presentation or adjuvant treatment received.

CONCLUSIONS

Hispanic patients with CRC in our catchment area present at a younger age with more metastatic disease and have a poorer survival than non-Hispanic Whites. Modification of screening criteria and treatment paradigms may be required for Hispanics.

Ten-year changes in cancer-related health behaviors and screening practices among Latino women and men in California

OBJECTIVE

This study examines changes in cancer-related health behaviors and risk factors (overweight/obesity, unhealthy diet, high alcohol use, and smoking), and screening practices related to cervical, breast, and colorectal cancer among Latinos of predominantly Mexican origin in Monterey County, California.

DESIGN

Data is from two cross-sectional surveys, conducted in 1990 and 2000, that included 919 women and 774 men from a community sample, and 276 men from an agricultural labor camp sample (ages 18-64).

RESULTS

Over the 10-year period, the prevalence of obesity increased by 48% among community women, 47% among community men, and 91% among labor camp men. Although consumption of fruits and vegetables remained low and consumption of fried foods remained high, other diet-related behaviors showed significant improvements (e.g. milk consumption shifted from whole-fat to lower-fat among women from the community and men from the labor camps, use of lard or meat fat when cooking decreased among women and men from the community). In addition, alcohol intake decreased among men from both samples, as did smoking among labor camp men. There were large improvements for annual pap and mammography screening (increases from 53 to 71% for pap testing, and from 15 to 53% for mammography screening) but annual blood stool testing remained infrequent and unchanged.

CONCLUSION

These findings highlight the need for interventions and policies that improve knowledge, preventive care, and social environments to sustain improvements and address areas of special need in cancer prevention for Latinos, especially related to obesity and colorectal screening.

Las Mujeres Saludables: Reaching Latinas for Breast, Cervical and Colorectal Cancer Prevention and Screening

Community health advisors have effectively promoted breast and cervical cancer prevention and screening among low-income Latina women. Specific elements of such programs, such as enhanced social support, may explain successes. Promotion of colorectal cancer screening has been less studied. Promotoras de Salud (i.e., Latina health advisors) implemented a 12-week program among women recruited from community-based organizations. The program educated 366 Latinas in breast, cervical and colorectal cancer prevention and screening and emphasized social support among class members. Pre- and post-intervention assessments demonstrated significant increases for fruit and vegetable consumption (3.05 to 3.60 servings/day), and physical activity (65.15 to 122.40 minutes/week). Of women previously non-compliant, 39 percent, 31 percent and 4 percent received Pap tests, mammography, and fecal occult blood test (FOBT), respectively. A culturally aligned education program using community health advisors and emphasizing social support among participants may improve prevention and selected screening behaviors, but more intensive interventions may be required for colorectal cancer screening compliance.

Screening Preferences for Colorectal Cancer: A Patient Demographic Study

BACKGROUND

Colorectal cancer is a leading cause of cancer-related death. Screening for colorectal cancer is a rational and cost-effective strategy for reducing the incidence of colorectal cancer and related mortality. Despite endorsement by academic and health care organizations, patient awareness and compliance with screening is low, partly because of patient-related barriers to screening.

METHODS

A convenience sample of adults attending the internal medicine and family practice clinics of a community teaching hospital was studied. A description of fecal occult blood testing (FOBT), sigmoidoscopy, and colonoscopy procedures was given in a packet along with a questionnaire. The questionnaire focused on screening procedures followed in our hospital (i.e., yearly FOBT and sigmoidoscopy every 5 years or colonoscopy every 10 years for average-risk individuals).

RESULTS

Of the 193 patients who responded, 55% preferred sigmoidoscopy and FOBT, 29% chose colonoscopy, and 16% wanted no screening. Those with knowledge of someone with colon cancer or colon polyps reported a significantly higher preference for screening than those without such knowledge. Catholics were most likely to prefer no screening compared with non-Catholics. Ex-smokers (compared with all others) were more likely to want screening. Catholics were least likely to want colonoscopy. Patients with previous experience of colorectal screening preferred future screening. Those preferring no screening were significantly younger than those who expressed a preference for screening.

CONCLUSION

The results of this study demonstrate diversity in patient choices for colorectal cancer screening. A focus on people's preferences rather than on the test itself may help develop and target appropriate intervention for prevention of colorectal cancer.

Predictors of digital rectal examination in U.S. Latinos

BACKGROUND

Little is known about prostate and colorectal cancer knowledge, attitudes, and screening practices among U.S. Latino men. Even less is known about the population's subgroup variations. This study assessed predictors of having obtained digital rectal examinations (DREs) among four Latino subgroups.

METHODS

Findings in this report are based on a cross-sectional telephone survey conducted between October 1993 and June 1994 as part of a multisite demonstration project for cancer prevention and control. The survey was conducted in eight U.S. cities identified via census data as having relatively high concentrations of targeted Latino subgroups. The analysis included 1499 Latino men aged > or = 40 who self-identified as Central American, Cuban American, Mexican American, or Puerto Rican.

RESULTS

Overall, 53% of the sample reported ever having had a DRE and 68% reported ever having heard of the procedure. For all subgroups, the only significant predictor for obtaining a DRE was "ever heard of DRE." "Having your doctor discuss DRE" was a significant factor for Mexican Americans and Puerto Ricans.

CONCLUSIONS

The lack of a universal DRE cancer-screening model among Latino groups highlights the need to address barriers in the context of the population's diversity. Ecologic approaches and clinician communication with Latinos need to be tailored to accommodate subgroup differences in knowledge, attitude, and practices related to DRE.

Colorectal cancer screening in North Carolina: associations with diabetes mellitus and demographic and health characteristics

BACKGROUND

Diabetes mellitus (DM) may increase the risk of colorectal cancer, a leading cause of cancer death in the United States. This report examines factors associated with colorectal cancer screening, including DM status.

METHODS

Data from the 1993/1995/1997 North Carolina (NC) Behavioral Risk Factor Surveillance System were analyzed to assess self-reported screening rates within guidelines for sigmoidoscopy/proctoscopy (sig/proct) and fecal occult blood test (FOBT).

RESULTS

Overall, 28.6, 27.2, and 19.7% received a sig/proct, FOBT, or either test within guidelines, respectively. Screening rates varied according to some demographic variables, but not by DM status. However, DM status changed some relationships between screening and some demographic/health characteristics.

CONCLUSIONS

Colorectal cancer screening in NC is similar to national rates, but certain subgroups are less likely to get screened. Persons with DM are as likely to get colorectal cancer screening, but some groups with DM (ethnic minorities, persons of low socioeconomic status) may be at high risk for not getting screened. Educational efforts to increase screening should target these groups.

Cancer of the colon and rectum in California: trends in incidence by race/ethnicity, stage, and subsite

BACKGROUND

Incidence and mortality from cancer of the colon and rectum have declined in recent years in the United States and California, but reasons for the decline are unknown.

METHODS

Age-adjusted site-specific and stage-specific incidence rates were calculated for approximately 9,000 cases of in situ cancer and 120,000 cases of invasive cancer of the colon and rectum diagnosed between 1988 and 1996 among California residents and reported to the California Cancer Registry. Trends in incidence over time were measured using the estimated annual percent change.

RESULTS

Among non-Hispanic whites there was a decline in all sites and stages, but the decrease was most pronounced for rates of in situ and regional/distant tumors in the rectum and sigmoid which declined by about 4 to 7% a year. For tumors in the proximal colon, the decrease was statistically significant only for regional/distant tumors which declined about 2% a year. Among blacks, there was an approximately 7% annual decline in the incidence of regional/distant tumors of the rectum in women and a nearly 3% a year decrease in regional/distant tumors of the proximal colon in men. The decline in rates for Hispanics and Asian/Pacific Islanders was smaller and less consistent than for non-Hispanic whites.

CONCLUSIONS

The results confirm a overall decline in all stages of cancer of the colon and rectum in California, particularly among non-Hispanic white men and women. The decrease was most pronounced for tumors in the rectum and sigmoid colon and may be attributable to screening.