State disparities in colorectal cancer mortality patterns in the United States

Understanding gastrointestinal cancer mortality disparities in a racially and geographically diverse population

BACKGROUND

Gastrointestinal (GI) cancers represent a diverse group of diseases. We assessed differences in geographic and racial disparities in cancer-specific mortality across subtypes, overall and by patient characteristics, in a geographically and racially diverse US population.

METHODS

Clinical, sociodemographic, and treatment characteristics for patients diagnosed during 2009-2014 with colorectal cancer (CRC), pancreatic cancer, hepatocellular carcinoma (HCC), or gastric cancer in Georgia were obtained from the Surveillance, Epidemiology, and End Results Program database. Patients were classified by geography (rural or urban county) and race and followed for cancer-specific death. Multivariable Cox proportional hazards models were used to calculate stratified hazard ratios (HR) and 95% confidence intervals (CIs) for associations between geography or race and cancer-specific mortality.

RESULTS

Overall, 77% of the study population resided in urban counties and 33% were non-Hispanic Black (NHB). For all subtypes, NHB patients were more likely to reside in urban counties than non-Hispanic White patients. Residing in a rural county was associated with an overall increased hazard of cancer-specific mortality for HCC (HR = 1.15, 95% CI = 1.02-1.31), pancreatic (HR = 1.11, 95% CI = 1.03-1.19), and gastric cancer (HR = 1.17, 95% CI = 1.03-1.32) but near-null for CRC. Overall racial disparities were observed for CRC (HR = 1.18, 95% CI = 1.11-1.25) and HCC (HR = 1.12, 95% CI = 1.01-1.24). Geographic disparities were most pronounced among HCC patients receiving surgery. Racial disparities were pronounced among CRC patients receiving any treatment.

CONCLUSION

Geographic disparities were observed for the rarer GI cancer subtypes, and racial disparities were pronounced for CRC. Treatment factors appear to largely drive both disparities.

Exosomes derived from microRNA-129-5p-modified tumor cells selectively enhanced suppressive effect in malignant behaviors of homologous colon cancer cells

Exosome-encapsulated microRNAs (miRNAs) are novel diagnostic and predictive markers in colon cancer. Hence, the study of serum exosomal miRNAs in patients with colon cancer may help its diagnosis and treatment. PKH26-labeled exosomal uptake analysis identified whether exosomes transfer miRNA-129-5p to target cells. Transmission electron microscopy and dynamic light scattering analysis were applied to determine exosome morphology and size distribution. The Cell Counting Kit-8, wound healing assay and Transwell assays were used to detect cell proliferation, migration, and invasion after treatment with engineered exosomes. Moreover, the Western blotting was used to quantify the expression of proteins involved in cell apoptosis. In our study, hepatocellular liver carcinoma, cervical cancer and colon cancer cells were selected as the target cells of miRNA-129-5p exosomes. Exosomes containing miRNA-129-5p were found to be significantly more easily absorbed by colon cancer cells, presenting a stronger inhibitory effect on colon cancer cell proliferation. MiRNA-129-5p exosomes induced apoptosis in colon cancer cells while inhibiting their proliferation, migration, and invasion. In conclusion, exosomes derived from miRNA-129-5p-modified tumor cells selectively inhibited colon cancer progression, shedding new insights to therapeutic efficacy of this cancer.

Prevalence of mammary Paget's disease in urban China in 2016

No national data have been available on descriptive epidemiology of mammary Paget's disease (MPD) in China. This population-based study aimed to estimate the prevalence of MPD and its pattens by sex, age and area in China. We conducted a population-based study using data in 2016 from China's Urban Employee Basic Medical Insurance and Urban Resident Basic Medical Insurance, covering approximately 0.43 billion residents. MPD cases were identified based on the diagnostic names and codes in claim data. A total of 825 patients of confirmed diagnosis of MPD were found during the study period. The prevalence of MPD in 2016 was 0.42 per 100,000 population (95% CI 0.19 to 0.73), with marked female predominance. The prevalence rates peaked at 40-59 years and ≥ 80 years in females and males, respectively. The prevalence rates varied among different regions, ranging from 0.06 (95% CI 0.00 to 0.23) in Northeast China to 1.21 (95% CI 0.07 to 3.72) in Northwest China. MPD showed marked female predominance in China. Chinese female patients were much younger, with lower prevalence than that in the United States. Obvious sex difference in the age pattern of MPD prevalence was also observed in China.

Community Health Behaviors and Geographic Variation in Early-Onset Colorectal Cancer Survival Among Women

INTRODUCTION

Despite overall reductions in colorectal cancer (CRC) morbidity and mortality, survival disparities by sex persist among young patients (age <50 years). Our study sought to quantify variance in early-onset CRC survival accounted for by individual/community-level characteristics among a population-based cohort of US women.

METHODS

Geographic hot spots-counties with high early-onset CRC mortality rates among women-were derived using 3 geospatial autocorrelation approaches with Centers for Disease Control and Prevention national mortality data. We identified women (age: 15-49 years) diagnosed with CRC from 1999 to 2016 in the National Institutes of Health/National Cancer Institute's Surveillance, Epidemiology, and End Results program. Patterns of community health behaviors by hot spot classification were assessed by Spearman correlation (ρ). Generalized R values were used to evaluate variance in survival attributed to individual/community-level features.

RESULTS

Approximately 1 in every 16 contiguous US counties identified as hot spots (191 of 3,108), and 52.9% of hot spot counties (n = 101) were located in the South. Among 28,790 women with early-onset CRC, 13.7% of cases (n = 3,954) resided in hot spot counties. Physical inactivity and fertility were community health behaviors that modestly correlated with hot spot residence among women with early-onset CRC (ρ = 0.21 and ρ = -0.23, respectively; P < 0.01). Together, individual/community-level features accounted for distinct variance patterns in early-onset CRC survival among women (hot spot counties: 33.8%; non-hot spot counties: 34.1%).

DISCUSSION

Individual/community-level features accounted for approximately one-third of variation in early-onset CRC survival among women and differed between hot spot vs non-hot spot counties. Understanding the impact of community health behaviors-particularly in regions with high early-onset CRC mortality rates-is critical for tailoring strategies to reduce early-onset CRC disparities.

Adherence to neoadjuvant therapy guidelines for locally advanced rectal cancers in a region with sociodemographic disparities

BACKGROUND

Practice guidelines recommend neoadjuvant chemoradiation (NCR) for locally advanced rectal cancer (LARC). We examined guideline adherence in a healthcare system serving a region with socioeconomic disparities and poor cancer outcomes.

METHODS

Retrospective analysis of factors associated with guideline adherence.

RESULTS

63.1% of stage II/III LARC patients received NCR. Factors associated with adherence included white race (OR = 2.15, p = 0.024), private insurance (OR = 2.70, p = 0.005), employed status (OR = 2.30, p = 0.031), age at diagnosis (OR = 0.74, p = 0.032), appropriate local staging (OR = 9.17, p < 0.0001), and diagnosis later in the study period (OR per 1 year = 1.20, p = 0.006). By multivariate analysis, private insurance (OR = 2.51, p = 0.023), younger age (OR per 10 years = 0.72, p = 0.048) and appropriate local staging (OR = 6.67, p < 0.0001) were associated with adherence.

CONCLUSION

Guideline adherence for LARC in our system is low and is impacted by employment, race and insurance status. Standard of care compliance remains an important target for improvement efforts in this underserved region of the nation's Mid-South.

Making FIT Count: Maximizing Appropriate Use of the Fecal Immunochemical Test for Colorectal Cancer Screening Programs

Colorectal cancer (CRC) remains one of the most common and deadly malignancies despite advancements in screening, diagnostic capabilities, and treatment. The ability to detect and remove precancerous and cancerous lesions via screening has altered the epidemiology of the disease, decreasing incidence, mortality, and late-stage disease presentation. The fecal immunochemical test (FIT) is a screening test that aims to detect human hemoglobin in the stool. FIT is the most common CRC screening modality worldwide and second most common in the United States. Its use in screening programs has been shown to increase screening uptake and improve CRC outcomes. However, FIT-based screening programs vary widely in quality and effectiveness. In health systems with high-quality FIT screening programs, only superior FIT formats are used, providers order FIT appropriately, annual patient participation is high, and diagnostic follow-up after an abnormal result is achieved in a timely manner. Proper utilization of FIT involves multiple steps beyond provider recommendation of the test. In this commentary, we aim to highlight ongoing challenges in FIT screening and suggest interventions to maximize FIT effectiveness. Through active engagement of patients and providers, health systems can use FIT to help optimize CRC screening rates and improve CRC outcomes.

Planned Short-Course Radiation (scRT) is Superior to Upfront Concurrent Chemoradiation (CCRT) in Treating Metastatic Rectal Cancer

BACKGROUND OR PURPOSE

To compare the cost-performance between planned short-course radiation and upfront concurrent chemoradiation on metastatic rectal cancer.

METHODS

A total of 75 patients with metastatic rectal cancer who underwent planned short-course radiation or upfront concurrent chemoradiation were enrolled. The Kaplan-Meier method was used to compute the survival rates. The χ² test was used to compare baseline characteristics. The Cox proportional hazards model was applied to determine the prognostic influence of clinicopathological factors.

RESULTS

The planned short-course radiation is superior to upfront concurrent chemoradiation in overall survival for the patients with metastatic rectal cancer (34.8 vs. 20.2 months, P = 0.010). The planned short-course radiation was an independent prognostic factor (P = 0.009, HR (95% CI) = 0.319(0.135-0.752)). The efficacy of radiation on downstaging was similar between planned short-course radiation and upfront concurrent chemoradiation. The total cost of concurrent chemoradiation is 4.52-fold more expensive than that of short-course radiation (340,142 vs. 75,106 NT dollars, respectively).

CONCLUSIONS

Based on the impressive cost-performance of planned short-course radiation compared with upfront concurrent chemoradiation (better OS, modest downstaging and lower cost), planned short-course radiation should be the preferred radiation approach for managing metastatic rectal cancer.

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.

Geospatial analysis of the influence of family doctor on colorectal cancer screening adherence

BACKGROUND

Despite the well-recognised relevance of screening in colorectal cancer (CRC) control, adherence to screening is often suboptimal. Improving adherence represents an important public health strategy. We investigated the influence of family doctors (FDs) as determinant of CRC screening adherence by comparing each FDs practice participation probability to that of the residents in the same geographic areas using the whole population geocoded.

METHODS

We used multilevel logistic regression model to investigate factors associated with CRC screening adherence, among 333,843 people at their first screening invitation. Standardized Adherence Rates (SAR) by age, gender, and socioeconomic status were calculated comparing FDs practices to the residents in the same geographic areas using geocoded target population.

RESULTS

Screening adherence increased from 41.0% (95% CI, 40.8-41.2) in 2006-2008 to 44.7% (95% CI, 44.5-44.9) in 2011-2012. Males, the most deprived and foreign-born people showed low adherence. FD practices and the percentage of foreign-born people in a practice were significant clustering factors. SAR for 145 (21.4%) FDs practices differed significantly from people living in the same areas. Predicted probabilities of adherence were 31.7% and 49.0% for FDs with low and high adherence, respectively.

DISCUSSION

FDs showed a direct and independent effect to the CRC screening adherence of the people living in their practice. FDs with significantly high adherence level could be the key to adherence improvement.

IMPACT

Most deprived individuals and foreigners represent relevant targets for interventions in public health aimed to improve CRC screening adherence.

The American Cancer Society 2035 challenge goal on cancer mortality reduction

A summary evaluation of the 2015 American Cancer Society (ACS) challenge goal showed that overall US mortality from all cancers combined declined 26% over the period from 1990 to 2015. Recent research suggests that US cancer mortality can still be lowered considerably by applying known interventions broadly and equitably. The ACS Board of Directors, therefore, commissioned ACS researchers to determine challenge goals for reductions in cancer mortality by 2035. A statistical model was used to estimate the average annual percent decline in overall cancer death rates among the US general population and among college-educated Americans during the most recent period. Then, the average annual percent decline in the overall cancer death rates of college graduates was applied to the death rates in the general population to project future rates in the United States beginning in 2020. If overall cancer death rates from 2020 through 2035 nationally decline at the pace of those of college graduates, then death rates in 2035 in the United States will drop by 38.3% from the 2015 level and by 54.4% from the 1990 level. On the basis of these results, the ACS 2035 challenge goal was set as a 40% reduction from the 2015 level. Achieving this goal could lead to approximately 1.3 million fewer cancer deaths than would have occurred from 2020 through 2035 and 122,500 fewer cancer deaths in 2035 alone. The results also show that reducing the prevalence of risk factors and achieving optimal adherence to evidence-based screening guidelines by 2025 could lead to a 33.5% reduction in the overall cancer death rate by 2035, attaining 85% of the challenge goal.

A Novel Type of Blood Biomarker: Distinct Changes of Cytokine-Induced STAT Phosphorylation in Blood T Cells Between Colorectal Cancer Patients and Healthy Individuals

Background: Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths worldwide. Although early diagnosis and treatment is the most successful strategy for improving patient survival, feasible and sensitive blood biomarkers for CRC screening remain elusive. Methods: Sixty-five CRC patients and thirty-three healthy individuals were enrolled. Peripheral blood (PB) and tumor tissues from CRC patients, and PB from healthy individuals were subjected to immunophenotyping and phospho-flow analysis of cytokine-induced phosphorylated STAT (CIPS). Logistic regression was used as a classifier that separates CRC patients from healthy individuals. Results: The proportion of regulatory T cells was increased in PB from CRC patients compared to PB from healthy individuals (p < 0.05). Interestingly, peripheral T cells share several cytokine-induced phosphorylated STAT (CIPS) signatures with T cells from CRC tumor-sites. Additionally, a classifier was made using two signatures distinct between T cells from CRC patients and T cells from healthy individuals. The AUCs (area under curves) of the classifier were 0.88 in initial cohort and 0.94 in the additional validation cohort. Overall AUC was 0.94 with sensitivity of 91% and specificity of 88%. Conclusion: This study highlights that immune cell signatures in peripheral blood could offer a new type of biomarker for CRC screening.

Examining determinants of geographic variation in colorectal cancer mortality in North Carolina: A spatial analysis approach

PURPOSE

A recent study using national data from 2000 to 2009 identified colorectal cancer (CRC) mortality "hotspots" in 11 counties of North Carolina (NC). In this study, we used more recent, state-specific data to investigate the county-level determinants of geographic variation in NC through a geospatial analytic approach.

METHOD

Using NC CRC mortality data from 2003 to 2013, we first conducted clustering analysis to confirm spatial dependence. Spatial economic models were then used to incorporate spatial structure to estimate the association between determinants and CRC mortality. We included county-level data on socio-demographic characteristics, access and quality of healthcare, behavioral risk factors (CRC screening, obesity, and cigarette smoking), and urbanicity. Due to correlation among screening, obesity and quality of healthcare, we combined these factors to form a cumulative risk group variable in the analysis.

RESULTS

We confirmed the existence of spatial dependence and identified clusters of elevated CRC mortality rates in NC counties. Using a spatial lag model, we found significant interaction effect between CRC risk groups and socioeconomic deprivation. Higher CRC mortality rates were also associated with rural counties with large towns compared to urban counties.

CONCLUSION

Our findings depicted a spatial diffusion process of CRC mortality rates across NC counties, demonstrated intertwined effects between SES deprivation and behavioral risks in shaping CRC mortality at area-level, and identified counties with high CRC mortality that were also deprived in multiple factors. These results suggest interventions to reduce geographic variation in CRC mortality should develop multifaceted strategies and work through shared resources in neighboring areas.

An assessment of progress in cancer control

This article summarizes cancer mortality trends and disparities based on data from the National Center for Health Statistics. It is the first in a series of articles that will describe the American Cancer Society's vision for how cancer prevention, early detection, and treatment can be transformed to lower the cancer burden in the United States, and sets the stage for a national cancer control plan, or blueprint, for the American Cancer Society goals for reducing cancer mortality by the year 2035. Although steady progress in reducing cancer mortality has been made over the past few decades, it is clear that much more could, and should, be done to save lives through the comprehensive application of currently available evidence-based public health and clinical interventions to all segments of the population. CA Cancer J Clin 2018;000:000-000. © 2018 American Cancer Society.

Accelerating the Pace of Cancer Prevention- Right Now

As a nation, we underinvest in prevention and fail to implement strategies that ensure all population groups equitably share in the return on investment in prevention research and the benefits of prevention effectiveness. There is significant evidence indicating that by applying knowledge that we already have to reduce tobacco, inactivity, and obesity (known modifiable causes of cancer), we can prevent more than 50% of cancers. Vaccination against HPV, aspirin and selective estrogen receptor modulators, and screening programs further reduce risk. Evidence-based prevention strategies are inconsistently implemented across the United States. Substantial variation across States indicates that there is much room for improvement in implementation of prevention. Implementation science applies innovative approaches to identifying, understanding, and developing strategies for overcoming barriers to the adoption, adaptation, integration, scale-up, and sustainability of evidence-based interventions, tools, policies, and guidelines that will prevent cancer through application of evidence-based interventions. When we get implementation of prevention programs right and at scale, we achieve substantial population benefits. Although many efforts are underway to maximize our knowledge about the causes and treatments of cancer, we can achieve reductions in the cancer burden right now by doing what we already know. The time to start is now. Cancer Prev Res; 11(4); 171-84. ©2018 AACR.

Better Late than Never? Adherence to Adjuvant Therapy Guidelines for Stage III Colon Cancer in an Underserved Region

INTRODUCTION

In 2008, the American College of Surgeons Commission on Cancer (CoC) issued a quality guideline for stage III colon cancer (CC) recommending adjuvant chemotherapy (AC) within 120 days of diagnosis. We examined adherence in a healthcare system serving a region with disparities in CC outcomes.

METHODS

In a retrospective analysis of patients (2005-2014) with stage III CC in a multi-hospital healthcare system, the associations between adherence, clinicopathologic, demographic, geographic, and socioeconomic data and overall survival (OS) were examined.

RESULTS

Of 1171 CC patients, 438 (37.4%) had stage III disease with 63% (n = 276) receiving AC and 37% (n = 162) not. AC conferred a 5-year OS advantage (62.4 vs. 42.5%, p < 0.0001). Younger age independently predicted AC receipt (OR = 0.95, p < 0.0001). Of 252 AC patients < 80 years, 75.8% were CoC guideline compliant (GC) whereas 24.2% were not (nGC). Although there was no OS difference between GC and nGC, both had superior survival (p < 0.0001) compared to non-AC patients. Surgical complications trended towards independent association with non-compliance (p = 0.07) CONCLUSION: Guideline compliance in our system (63%) is lower than the CoC Estimated Performance Rate (72.4%). Age influenced absolute receipt of AC while surgical complications may impact guideline compliance. Even when administered beyond 120 days, AC was associated with a survival benefit.

A geographic information system-based method for estimating cancer rates in non-census defined geographical areas

PURPOSE

To address locally relevant cancer-related health issues, health departments frequently need data beyond that contained in standard census area-based statistics. We describe a geographic information system-based method for calculating age-standardized cancer incidence rates in non-census defined geographical areas using publically available data.

METHODS

Aggregated records of cancer cases diagnosed from 2009 through 2013 in each of Chicago's 77 census-defined community areas were obtained from the Illinois State Cancer Registry. Areal interpolation through dasymetric mapping of census blocks was used to redistribute populations and case counts from community areas to Chicago's 50 politically defined aldermanic wards, and ward-level age-standardized 5-year cumulative incidence rates were calculated.

RESULTS

Potential errors in redistributing populations between geographies were limited to <1.5% of the total population, and agreement between our ward population estimates and those from a frequently cited reference set of estimates was high (Pearson correlation r = 0.99, mean difference = -4 persons). A map overlay of safety-net primary care clinic locations and ward-level incidence rates for advanced-staged cancers revealed potential pathways for prevention.

CONCLUSIONS

Areal interpolation through dasymetric mapping can estimate cancer rates in non-census defined geographies. This can address gaps in local cancer-related health data, inform health resource advocacy, and guide community-centered cancer prevention and control.

Geographic and population-level disparities in colorectal cancer testing: A multilevel analysis of Medicaid and commercial claims data

Morbidity and mortality from colorectal cancer (CRC) can be attenuated through guideline concordant screening and intervention. This study used Medicaid and commercial claims data to examine individual and geographic factors associated with CRC testing rates in one state (Oregon). A total of 64,711 beneficiaries (4516 Medicaid; 60,195 Commercial) became newly age-eligible for CRC screening and met inclusion criteria (e.g., continuously enrolled, no prior history) during the study period (January 2010-December 2013). We estimated multilevel models to examine predictors for CRC testing, including individual (e.g., gender, insurance, rurality, access to care, distance to endoscopy facility) and geographic factors at the county level (e.g., poverty, uninsurance). Despite insurance coverage, only two out of five (42%) beneficiaries had evidence of CRC testing during the four year study window. CRC testing varied from 22.4% to 46.8% across Oregon's 36 counties; counties with higher levels of socioeconomic deprivation had lower levels of testing. After controlling for age, beneficiaries had greater odds of receiving CRC testing if they were female (OR 1.04, 95% CI 1.01-1.08), commercially insured, or urban residents (OR 1.14, 95% CI 1.07-1.21). Accessing primary care (OR 2.47, 95% CI 2.37-2.57), but not distance to endoscopy (OR 0.98, 95% CI 0.92-1.03) was associated with testing. CRC testing in newly age-eligible Medicaid and commercial members remains markedly low. Disparities exist by gender, geographic residence, insurance coverage, and access to primary care. Work remains to increase CRC testing to acceptable levels, and to select and implement interventions targeting the counties and populations in greatest need.

Increasing Incidence of Colorectal Cancer in Adolescents and Young Adults Aged 15-39 Years in Western Australia 1982-2007: Examination of Colonoscopy History

Aims

To examine trends in colorectal cancer (CRC) incidence and colonoscopy history in adolescents and young adults (AYAs) aged 15–39 years in Western Australia (WA) from 1982 to 2007.

Design

Descriptive cohort study using population-based linked hospital and cancer registry data.

Method

Five-year age-standardized and age-specific incidence rates of CRC were calculated for all AYAs and by sex. Temporal trends in CRC incidence were investigated using Joinpoint regression analysis. The annual percentage change (APC) in CRC incidence was calculated to identify significant time trends. Colonoscopy history relative to incident CRC diagnosis was examined and age and tumor grade at diagnosis compared for AYAs with and without pre-diagnosis colonoscopy. CRC-related mortality within 5 and 10 years of incident diagnosis were compared for AYAs with and without pre-diagnosis colonoscopy using mortality rate ratios (MRRs) derived from negative binomial regression.

Results

Age-standardized CRC incidence among AYAs significantly increased in WA between 1982 and 2007, APC = 3.0 (95% CI 0.7–5.5). Pre-diagnosis colonoscopy was uncommon among AYAs (6.0%, 33/483) and 71% of AYAs were diagnosed after index (first ever) colonoscopy. AYAs with pre-diagnosis colonoscopy were older at CRC diagnosis (mean 36.7 ± 0.7 years) compared to those with no prior colonoscopy (32.6 ± 0.2 years), p < 0.001. At CRC diagnosis, a significantly greater proportion of AYAs with pre-diagnosis colonoscopy had well-differentiated tumors (21.2%) compared to those without (5.6%), p = 0.001. CRC-related mortality was significantly lower for AYAs with pre-diagnosis colonoscopy compared to those without, for both 5-year [MRR = 0.44 (95% CI 0.27–0.75), p = 0.045] and 10-year morality [MRR = 0.43 (95% CI 0.24–0.83), p = 0.043].

Conclusion

CRC incidence among AYAs in WA has significantly increased over the 25-year study period. Pre-diagnosis colonoscopy is associated with lower tumor grade at CRC diagnosis as well as significant reduction in both 5- and 10-year CRC-related mortality rates. These findings warrant further research into the balance in benefits and harms of targeted screening for AYA at highest risk.

Is the clinicopathological pattern of colorectal carcinoma similar in the state and private healthcare systems of South Africa? Analysis of a Durban colorectal cancer database

Previous state hospital-based local studies suggest varying population-based clinicopathological patterns of colorectal cancer (CRC). Patients diagnosed with CRC in the state and private sector hospitals in Durban, South Africa over a 12-month period (January-December 2009) form the basis of our study. Of 491 patients (172 state and 319 private sector patients), 258 were men. State patients were younger than private patients. Anatomical site distribution was similar in both groups with minor variations. Stage IV disease was more common in state patients. State patients were younger, presented with advanced disease and had a lower resection rate. Black patients were the youngest, presented with advanced disease and had the lowest resection rate.

Colorectal Cancer Trends in California and the Need for Greater Screening of Hispanic Men

INTRODUCTION

Colorectal cancer (CRC) incidence and mortality rates have decreased dramatically since 1990, both nationally and in California, except among Hispanic men. This study examined trends in CRC incidence, mortality, and survival to determine likely contributing factors for the differential trends between Hispanic and non-Hispanic white men in California.

METHODS

California Cancer Registry data were used to identify 23,157 Hispanic and 114,944 white men diagnosed with CRC between 1990 and 2012. Joinpoint trends in incidence, mortality, and 5-year relative survival were examined by age, stage at diagnosis, and tumor location. Data used in the study were extracted from the California Cancer Registry database and analyzed in 2015.

RESULTS

Both incidence and mortality rates decreased substantially among white men between 1990 and 2012, but no corresponding decrease was observed among Hispanic men. Both groups experienced similar trends in survival and stage at diagnosis over time. White men had greater declines in CRC incidence and mortality in all age groups, particularly those aged >50 years. Hispanic men had a significantly higher proportion (65%) of tumors in the distal colon than white men (59%).

CONCLUSIONS

CRC incidence and mortality rates have decreased among white men since 1990, but not among Hispanic men. Results from this study suggest lower screening rates may be an important reason why CRC rates in California did not decline in Hispanic men. Effective strategies aimed at both Hispanics and their healthcare providers are needed to increase CRC screening among Hispanic men and reduce their CRC burden.

Impact of Health Insurance Expansion on the Treatment of Colorectal Cancer

Purpose Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the United States. Lack of insurance coverage has been associated with more advanced disease at presentation, more emergent admissions at time of colectomy, and lower survival relative to privately insured patients. The 2006 Massachusetts health care reform serves as a unique natural experiment to assess the impact of insurance expansion on colorectal cancer care. Methods We used the Hospital Cost and Utilization Project State Inpatient Databases to identify patients with colorectal cancer with government-subsidized or self-pay (GSSP) or private insurance admitted to a hospital between 2001 and 2011 in Massachusetts (n = 17,499) and three control states (n = 144,253). Difference-in-differences models assessed the impact of the 2006 Massachusetts coverage expansion on resection of colorectal cancer, controlling for confounding factors and secular trends. Results Before the 2006 Massachusetts reform, government-subsidized or self-pay patients had significantly lower rates of resection for colorectal cancer compared with privately insured patients in both Massachusetts and the control states. The Massachusetts insurance expansion was associated with a 44% increased rate of resection (rate ratio = 1.44; 95% CI, 1.23 to 1.68; P < .001), a 6.21 percentage point decreased probability of emergent admission (95% CI, -11.88 to -0.54; P = .032), and an 8.13 percentage point increased probability of an elective admission (95% CI, 1.34 to 14.91; P = .019) compared with the control states. Conclusion The 2006 Massachusetts health care reform, a model for the Affordable Care Act, was associated with increased rates of resection and decreased probability of emergent resection for colorectal cancer. Our findings suggest that insurance expansion may help improve access to care for patients with colorectal cancer.

Inhibitory effects of dieckol on hypoxia-induced epithelial-mesenchymal transition of HT29 human colorectal cancer cells

Hypoxia-induced epithelial-mesenchymal transition (EMT) has been identified as essential for tumor progression and metastasis. The present study examined the effects of an antioxidant, dieckol, on hypoxia-induced EMT in HT29 human colorectal cancer cells. HT29 cells were treated with a hypoxia-inducing agent, CoCl₂, and an increase in the levels of intracellular reactive oxygen species (ROS) and various morphological changes, such as loss of cell-cell contact and aggressive cell migration were observed. CoCl₂ also induced an increase in the expression of hypoxia-inducible factor 1α (HIF1α) and various mesenchymal-specific markers, including vimentin and snail family transcriptional repressor 1 (Snail1), and a decrease in the expression of E-cadherin, thus suggesting that CoCl₂ induced EMT in HT29 cells. Conversely, the CoCl₂-induced EMT of HT29 cells was suppressed following treatment with dieckol. In addition, ROS generation, EMT marker protein expression and intracellular localization, cell migration and cell invasion were attenuated following dieckol treatment. The findings of the present study suggested that dieckol may inhibit hypoxia-induced EMT in HT29 cells by regulating the levels of cellular ROS and protein expression levels downstream of the HIF1α signaling pathway. Therefore, dieckol has the potential to become an attractive therapeutic agent for the treatment of colorectal cancer.

Extending Colorectal Cancer Screening to Persons Aged 40 to 49 Years With Immunochemical Fecal Occult Blood Test: A Prospective Cohort Study of 513,283 Individuals

GOALS

To assess the association between the initial immunochemical fecal occult blood tests (FIT) and subsequent colorectal cancer, and to explore the ability of FIT to identify individuals age 40 to 49 years with a higher cancer risk.

BACKGROUND

The number of cancer cases in this age group is increasing globally and the cancers found in younger age tend to be more advanced than in older age.

METHODS

A total of 513,283 individuals had FIT as part of their self-paying medical screening program between 1994 and 2008. The initial FIT test was used. When matched with the Taiwan cancer registry, the cohort identified 2138 colorectal cancer cases. The number needed to screen (NNS) to identify 1 cancer was calculated from the reciprocal of cancer incidence cases during the study period.

RESULTS

One in 7 colorectal cancers above age 40 years occurred in the age group of 40 to 49 years. Individuals 40 to 49 years old with positive FIT (≥100 ng/mL) had a 3 times larger cancer risk than those 50 to 59 years old and without FIT, or double the cancer risk as those 50 to 69 years old and without FIT, with NNS at 42, 135, and 95, respectively. A similar relationship existed for the cancer incidence rate. The HR for ages 40 to 44 years or 45 to 49 years with a positive FIT was 2.3 or 5.7 times larger than the HR for ages 50 to 54 years. There was a dose-response relationship between increasing FIT values and the cancer risk for each age group, including ages 40 to 49 years.

CONCLUSIONS

Offering FIT to individuals 40 to 49 years of age could identify higher-risk individuals earlier for follow-up colonoscopy, and could, in turn, reduce cancer mortality.

Counties eliminating racial disparities in colorectal cancer mortality

BACKGROUND

Although colorectal cancer (CRC) mortality rates are declining, racial-ethnic disparities in CRC mortality nationally are widening. Herein, the authors attempted to identify county-level variations in this pattern, and to characterize counties with improving disparity trends.

METHODS

The authors examined 20-year trends in US county-level black-white disparities in CRC age-adjusted mortality rates during the study period between 1989 and 2010. Using a mixed linear model, counties were grouped into mutually exclusive patterns of black-white racial disparity trends in age-adjusted CRC mortality across 20 three-year rolling average data points. County-level characteristics from census data and from the Area Health Resources File were normalized and entered into a principal component analysis. Multinomial logistic regression models were used to test the relation between these factors (clusters of related contextual variables) and the disparity trend pattern group for each county.

RESULTS

Counties were grouped into 4 disparity trend pattern groups: 1) persistent disparity (parallel black and white trend lines); 2) diverging (widening disparity); 3) sustained equality; and 4) converging (moving from disparate outcomes toward equality). The initial principal component analysis clustered the 82 independent variables into a smaller number of components, 6 of which explained 47% of the county-level variation in disparity trend patterns.

CONCLUSIONS

County-level variation in social determinants, health care workforce, and health systems all were found to contribute to variations in cancer mortality disparity trend patterns from 1990 through 2010. Counties sustaining equality over time or moving from disparities to equality in cancer mortality suggest that disparities are not inevitable, and provide hope that more communities can achieve optimal and equitable cancer outcomes for all. Cancer 2016;122:1735-48. © 2016 American Cancer Society.

Trends in UK regional cancer mortality 1991-2007

Background:

Until 1990, there was an upward trend in mortality from breast, lung, prostate, and colon cancers in the United Kingdom. With improvements in cancer treatment there has, in general, been a fall in mortality over the last 20 years. We evaluate regional cancer mortality trends in the United Kingdom between 1991 and 2007.

Methods:

We analysed mortality trends for breast, lung, prostate, and colon cancers using data obtained from the EUREG cancer database. We have described changes in age-standardised rates (using European standard population) per 100 000 for cancer mortality and generated trends in mortality for the 11 regions using Joinpoint regression.

Results:

Across all regions in the United Kingdom there was a downward trend in mortality for the four most common cancers in males and females. Overall, deaths from colon cancer decreased most rapidly and deaths from prostate cancer decreased at the slowest rate. Similar downward trends in mortality were observed across all regions of the United Kingdom with the data for lung cancer exhibiting the greatest variation.

Conclusions:

Mortality from the four most common cancers decreased across all regions of the United Kingdom; however, the rate of decline varied between cancer type and in some instances by region.

Nurse Practitioner Knowledge of and Experienced Barriers to High-Risk Colorectal Cancer Screenings

Problem: Evidence supports earlier preventive colorectal cancer (CRC) screening for high-risk individuals. Awareness of high-risk factors and application to screening guidelines can enable nurse practitioners (NPs) to positively impact screening rates. Application of this knowledge can transform high-risk CRC screenings from tertiary CRC diagnosis to primary and secondary prevention to improve health outcomes. Purpose: To survey NP knowledge, perceived barriers, and current practice patterns in referring high-risk individuals for CRC screenings. Methods: A 16-question Qualtrics Internet survey designed, tested, and emailed to 2,155 primary care NPs in North Carolina. Results: One hundred eighty respondents (8.3%) completed the survey, with 57.5% (n = 104) rating themselves knowledgeable of high-risk CRC screening guidelines. Screening barriers included uninsured status, patient refusal, and lack of access. Aggregate practice screening pattern questions were related to self-perceived knowledge of high-risk CRC guidelines (χ² = 4.1918, df = 1, p = .04). Conclusion: Over half (57.8%) of the respondents reporting knowledge of high-risk CRC guidelines had statistically significant relationship in aggregate practice patterns. Reduction of screening barriers using targeted interventions may improve health outcomes.

Protein phosphatase methylesterase-1 (PME-1) expression predicts a favorable clinical outcome in colorectal cancer

Colorectal cancer (CRC) accounts for high mortality. So far, there is lack of markers capable of predicting which patients are at risk of aggressive course of the disease. Protein phosphatase-2A (PP2A) inhibitor proteins have recently gained interest as markers of more aggressive disease in certain cancers. Here, we report the role of PP2A inhibitor PME-1 in CRC. PME-1 expression was assessed from a rectal cancer patient cohort by immunohistochemistry, and correlations were performed for various clinicopathological variables and patient survival. Rectal cancer patients with higher cytoplasmic PME-1 protein expression (above median) had less recurrences (P = 0.003, n = 195) and better disease-free survival (DFS) than the patients with low cytoplasmic PME-1 protein expression (below median). Analysis of PPME-1 mRNA expression from TCGA dataset of colon and rectal adenocarcinoma (COADREAD) patient cohort confirmed high PPME1 expression as an independent protective factor predicting favorable overall survival (OS) (P = 0.005, n = 396) compared to patients with low PPME1 expression. CRC cell lines were used to study the effect of PME-1 knockdown by siRNA on cell survival. Contrary to other cancer types, PME-1 inhibition in CRC cell lines did not reduce the viability of cells or the expression of active phosphorylated AKT and ERK proteins. In conclusion, PME-1 expression predicts for a favorable outcome of CRC patients. The unexpected role of PME-1 in CRC in contrast with the oncogenic role of PP2A inhibitor proteins in other malignancies warrants further studies of cancer-specific function for each of these proteins.

The impact of preventive screening resource distribution on geographic and population-based disparities in colorectal cancer in Mississippi

Background

The state of Mississippi has the highest colorectal cancer (CRC) mortality rate in the USA. The geographic distribution of CRC screening resources and geographic- and population-based CRC characteristics in Mississippi are investigated to reveal the geographic disparity in CRC screening.

Methods

The primary practice sites of licensed gastroenterologists and the addresses of licensed medical facilities offering on-site colonoscopies were verified via telephone surveys, then these CRC screening resource data were geocoded and analyzed using Geographic Information Systems. Correlation analyses were performed to detect the strength of associations between CRC screening resources, CRC screening behavior and CRC outcome data.

Results

Age-adjusted colorectal cancer incidence rates, mortality rates, mortality-to-incidence ratios, and self-reported endoscopic screening rates from the years 2006 through 2010 were significantly different for Black and White Mississippians; Blacks fared worse than Whites in all categories throughout all nine Public Health Districts. CRC screening rates were negatively correlated with CRC incidence rates and CRC mortality rates. The availability of gastroenterologists varied tremendously throughout the state; regions with the poorest CRC outcomes tended to be underserved by gastroenterologists.

Conclusions

Significant population-based and geographic disparities in CRC screening behaviors and CRC outcomes exist in Mississippi. The effects of CRC screening resources are related to CRC screening behaviors and outcomes at a regional level, whereas at the county level, socioeconomic factors are more strongly associated with CRC outcomes. Thus, effective control of CRC in rural states with high poverty levels requires both adequate preventive CRC screening capacity and a strategy to address fundamental causes of health care disparities.

Cancer death rates in US congressional districts

Knowledge of the cancer burden is important for informing and advocating cancer prevention and control. Mortality data are readily available for states and counties, but not for congressional districts, from which representatives are elected and which may be more influential in compelling legislation and policy. The authors calculated average annual cancer death rates during 2002 to 2011 for each of the 435 congressional districts using mortality data from the National Center for Health Statistics and population estimates from the US Census Bureau. Age-standardized death rates were mapped for all sites combined and separately for cancers of the lung and bronchus, colorectum, breast, and prostate by race/ethnicity and sex. Overall cancer death rates vary by almost 2-fold and are generally lowest in Mountain states and highest in Appalachia and areas of the South. The distribution is similar for lung and colorectal cancers, with the lowest rates consistently noted in districts in Utah. However, for breast and prostate cancers, while the highest rates are again scattered throughout the South, the geographic pattern is less clear and the lowest rates are in Hawaii and southern Texas and Florida. Within-state heterogeneity is limited, particularly for men, with the exceptions of Texas, Georgia, and Florida. Patterns also vary by race/ethnicity. For example, the highest prostate cancer death rates are in the West and north central United States among non-Hispanic whites, but in the deep South among African Americans. Hispanics have the lowest rates except for colorectal cancer in Wyoming, eastern Colorado, and northern New Mexico. These data can facilitate cancer control and stimulate conversation about the relationship between cancer and policies that influence access to health care and the prevalence of behavioral and environmental risk factors.

Where can colorectal cancer screening interventions have the most impact?

BACKGROUND

Although colorectal cancer death rates in the United States have declined by half since 1970, large geographic disparities persist. Spatial identification of high-risk areas can facilitate targeted screening interventions to close this gap.

METHODS

We used the Getis-Ord Gi* statistic within ArcGIS to identify contemporary colorectal cancer "hotspots" (spatial clusters of counties with high rates) based on county-level mortality data from the national vital statistics system. Hotspots were compared with the remaining aggregated counties (non-hotspot United States) by plotting trends from 1970 to 2011 and calculating rate ratios (RR). Trends were quantified using joinpoint regression.

RESULTS

Spatial mapping identified three distinct hotspots in the contemporary United States where colorectal cancer death rates were elevated. The highest rates were in the largest hotspot, which encompassed 94 counties in the Lower Mississippi Delta [Arkansas (17), Illinois (16), Kentucky (3), Louisiana (6), Mississippi (27), Missouri (15), and Tennessee (10)]. During 2009 to 2011, rates here were 40% higher than the non-hotspot United States [RR, 1.40; 95% confidence interval (CI), 1.34-1.46], despite being 18% lower during 1970 to 1972 (RR, 0.82; 95% CI, 0.78-0.86). The elevated risk was similar in blacks and whites. Notably, rates among black men in the Delta increased steadily by 3.5% per year from 1970 to 1990, and have since remained unchanged. Rates in hotspots in west central Appalachia and eastern Virginia/North Carolina were 18% and 9% higher, respectively, than the non-hotspot United States during 2009 to 2011.

CONCLUSIONS

Advanced spatial analysis revealed large pockets of the United States with excessive colorectal cancer death rates.

IMPACT

These well-defined areas warrant prioritized screening intervention.

State disparities in colorectal cancer rates: Contributions of risk factors, screening, and survival differences

BACKGROUND

Northeastern states of the United States have shown more progress in reducing colorectal cancer (CRC) incidence and mortality rates than Southern states, and this has resulted in considerable disparities. This study quantified how the disparities in CRC rates between Louisiana (a Southern state) and New Jersey (a Northeastern state) would be affected if differences in risk factors, screening, and stage-specific CRC relative survival between the states were eliminated.

METHODS

This study used the Microsimulation Screening Analysis Colon microsimulation model to estimate age-adjusted CRC incidence and mortality rates in Louisiana from 1995 to 2009 under the assumption that 1) Louisiana had the same smoking and obesity prevalence observed in New Jersey, 2) Louisiana had the same CRC screening uptake observed in New Jersey, 3) Louisiana had the same stage-specific CRC relative survival observed in New Jersey, or 4) all the preceding were true.

RESULTS

In 2009, the observed CRC incidence and mortality rates in Louisiana were 141.4 cases and 61.9 deaths per 100,000 individuals, respectively. With the same risk factors and screening observed in New Jersey, the CRC incidence rate in Louisiana was reduced by 3.5% and 15.2%, respectively. New Jersey's risk factors, screening, and survival reduced the CRC mortality rate in Louisiana by 3.0%, 10.8%, and 17.4%, respectively. With all trends combined, the modeled rates per 100,000 individuals in Louisiana became lower than the observed rates in New Jersey for both incidence (116.4 vs 130.0) and mortality (44.7 vs 55.8).

CONCLUSIONS

The disparities in CRC incidence and mortality rates between Louisiana and New Jersey could be eliminated if Louisiana could attain New Jersey's levels of risk factors, screening, and survival. Priority should be given to enabling Southern states to improve screening and survival rates.

Optimal colorectal cancer screening in states' low-income, uninsured populations—the case of South Carolina

OBJECTIVE

To determine whether, given a limited budget, a state's low-income uninsured population would have greater benefit from a colorectal cancer (CRC) screening program using colonoscopy or fecal immunochemical testing (FIT).

DATA SOURCES/STUDY SETTING

South Carolina's low-income, uninsured population.

STUDY DESIGN

Comparative effectiveness analysis using microsimulation modeling to estimate the number of individuals screened, CRC cases prevented, CRC deaths prevented, and life-years gained from a screening program using colonoscopy versus a program using annual FIT in South Carolina's low-income, uninsured population. This analysis assumed an annual budget of $1 million and a budget availability of 2 years as a base case.

PRINCIPAL FINDINGS

The annual FIT screening program resulted in nearly eight times more individuals being screened, and more important, approximately four times as many CRC deaths prevented and life-years gained than the colonoscopy screening program. Our results were robust for assumptions concerning economic perspective and the target population, and they may therefore be generalized to other states and populations.

CONCLUSIONS

A FIT screening program will prevent more CRC deaths than a colonoscopy-based program when a state's budget for CRC screening supports screening of only a fraction of the target population.

GRP78 Protein Expression as Prognostic Values in Neoadjuvant Chemoradiotherapy and Laparoscopic Surgery for Locally Advanced Rectal Cancer

Purpose

We investigated the relationships between biomarkers related to endoplasmic reticulum stress proteins (glucose-regulated protein of molecular mass 78 [GRP78] and Cripto-1 [teratocarcinoma-derived growth factor 1 protein]), pathologic response, and prognosis in locally advanced rectal cancer.

Materials and Methods

All clinical stage II and III rectal cancer patients received 50.4 Gy over 5.5 weeks, plus 5-fluorouracil (400 mg/m²/day) and leucovorin (20 mg/m²/day) bolus on days 1 to 5 and 29 to 33, and surgery was performed at 7 to 10 weeks after completion of all therapies. Expression of GRP78 and Cripto-1 proteins was determined by immunohistochemistry and was assessed in 101 patients with rectal cancer treated with neoadjuvant chemoradiotherapy (CRT).

Results

High expression of GRP78 and Cripto-1 proteins was observed in 86 patients (85.1%) and 49 patients (48.5%), respectively. Low expression of GRP78 protein was associated with a significantly high rate of down staging (80.0% vs. 52.3%, respectively; p=0.046) and a significantly low rate of recurrence (0% vs. 33.7%, respectively; p=0.008) compared with high expression of GRP78 protein. Mean recurrence-free survival according to GRP78 expression could not be estimated because the low expression group did not develop recurrence events but showed a significant correlation with time to recurrence, based on the log rank method (p=0.007). GRP78 also showed correlation with overall survival, based on the log rank method (p=0.045).

Conclusion

GRP78 expression is a predictive and prognostic factor for down staging, recurrence, and survival in rectal cancer patients treated with 5-fluorouracil and leucovorin neoadjuvant CRT.

Peroxisome proliferator-activated receptor-α staining is associated with worse outcome in colorectal liver metastases

Peroxisome proliferator-activated receptors (PPARs) are a family of nuclear receptors involved in lipid metabolism and liver response to injury. We hypothesised that differences in the expression of PPARs may reflect differences in the cellular microenvironment of the liver and, consequently, in the behaviour of colorectal liver metastases. Of the 145 patients who underwent hepatectomy for colorectal liver metastases between 1998 and 2007, 103 had adequate tissue for PPAR staining and histological re-evaluation. The histological characteristics evaluated included sinusoidal dilatation, perisinusoidal fibrosis, ballooning and steatosis. PPAR- α and-γ staining was performed and the results were correlated with clinical and survival data. Lobular inflammation and sinusoidal dilatation were the most common histopathological abnormalities. A total of 50% of the patients were PPAR- α-negative and 34% were PPAR- γ-negative. More patients exhibited lobular inflammation in the PPAR- α -positive group (P=0.023) compared to patients with negative PPAR- α staining, as seen on the multivariate analysis. PPAR- γpositivity was associated with oxaliplatin use, surgical margins ≥1 mm and a trend towards a lesser degree of fibrosis. The median follow-up in this cohort of patients was 48 months. Patients with PPAR- α staining had a worse overall survival (median, 36 vs. 79 months, P=0.037) compared to those with no PPAR- α staining. There was no correlation between PPAR- α or-γpositivity and disease-free survival. In conclusion, PPAR- α staining is associated with lobular inflammation and worse overall survival in patients with colorectal liver metastases. The exact mechanism underlying this finding remains unclear and further research into the diagnostic and therapeutic implications is required.

Inequalities in premature death from colorectal cancer by state

PURPOSE

Although disparities in colorectal cancer (CRC) with regard to race, socioeconomic status, and geography are well documented, the extent to which these factors contribute to premature death resulting from CRC nationwide and by state is unknown.

PATIENTS AND METHODS

We calculated age-standardized CRC death rates for three broad educational categories as a marker of socioeconomic status by race/ethnicity and state among individuals age 25 to 64 years from 2008 through 2010. We also calculated the proportion of premature death resulting from CRC that could potentially be averted in each state by applying the average death rate for the five states with the lowest rates among the most educated whites (Connecticut, North Dakota, Utah, Vermont, and Wisconsin) to all populations.

RESULTS

Compared with those with the most education, those with the least education had significantly higher CRC death rates in virtually all states for each racial/ethnic group. For example, rate ratios ranged from 1.15 (95% CI, 0.66 to 2.01) in Delaware to 3.18 (95% CI, 2.01 to 5.05) in New Mexico among whites. Overall, half the premature deaths resulting from CRC that occurred nationwide from 2008 through 2010, or 7,690 deaths annually, would have been avoided if everyone had experienced the lowest death rates of the most educated whites. More premature deaths could be averted in southern states (60% to 70%) than in northern and western states (30% to 40%). Restricting the analyses to persons age 50 to 64 years, for whom CRC screening is recommended, resulted in similar findings.

CONCLUSION

The majority of premature deaths from CRC in southern states and half these deaths nationwide are due to racial/ethnic, socioeconomic, and geographic inequalities.

Role of CHD1L in migration and invasion of human colon cancer cells

AIM: To examine the expression of chromodomain helicase/ATPase DNA binding protein 1-like gene (CHD1L) in colorectal cancer and to investigate its role in colorectal cancer cell migration and invasion.

METHODS: The expression of CHD1L in colorectal cancer and adjacent tissues was detected by fluorescence quantitative PCR and Western blot. The migration and invasion abilities of colorectal cancer cells overexpressing or underexpressing CHD1L were examined by scratch-wound migration and transwell invasion assays.

RESULTS: CHD1L mRNA and protein expression in colorectal cancer tissues was significantly higher than that in matched adjacent tissues. CHD1L in colon cancer cell lines also showed high expression. Transfection with CHD1L-shRNA in LOVO and DLD-1 cells significantly reduced the expression of CHD1L mRNA and protein, and inhibited the invasion and migration of cancer cells. In vivo experiments further showed that knockdown of CHD1L dramatically decreased the incidence of intrahepatic and lung metastases.

CONCLUSION: CHD1L is highly expressed in colorectal cancer tissues and cells, and it plays an important role in colorectal cancer invasion and migration. CHD1L may become a new target for treatment of colorectal cancer.

Differences in response to a dietary intervention between the general population and first-degree relatives of colorectal cancer patients

OBJECTIVE

To determine whether response to a dietary intervention is greater among people with family history of colorectal cancer (CRC) compared with a general population.

DESIGN

Cohort study examining participants from 2 related studies.

SETTING

Rural Virginia.

PARTICIPANTS

Seventy people with first-degree relatives with CRC and 113 participants from the intervention arm of a trial in the general population.

INTERVENTION

Both studies implemented a low-intensity intervention delivered via telephone and mail, including low-literacy self-help booklets and personalized dietary feedback.

MAIN OUTCOME MEASURES

Fat, fiber, and fruit and vegetable behavior.

ANALYSIS

Propensity score matching controlled for confounders. Mixed-model ANOVAs compared samples; mediation by perceived cancer risk was assessed.

RESULTS

Participants in both groups significantly improved fat, fiber, and fruit and vegetable behavior at 1-month follow-up; there was significantly greater improvement in the general population sample. Cancer risk perception did not mediate the relationship between study sample and dietary change.

CONCLUSIONS AND IMPLICATIONS

Contrary to expectations, first-degree relatives of CRC patients did not respond better to a dietary intervention than the general population, nor was risk perception related to dietary change. Given the role of diet in CRC risk, additional research should investigate targeted strategies to improve dietary intakes of people at higher cancer risk.

Evaluation of the walk-through inflatable colon as a colorectal cancer education tool: results from a pre and post research design

BACKGROUND

Colorectal cancer (CRC) is a disease that can be prevented through early detection. Through the use of effective educational tools, individuals can become better informed about CRC and understand the importance of screening and early detection. The walk through Inflatable Colon is an innovative educational resource developed to engage and educate communities on CRC and the importance of receiving screening at the appropriate ages.

METHODS

The Inflatable Colon Assessment Survey (ICAS) assessed knowledge and behavioral intentions to obtain screening and promote CRC awareness. New Mexico State University faculty, staff, and students completed a consent form, took the pre-ICAS, toured the Inflatable Colon, and completed the post-ICAS. The majority of participants (92%) were young adults, mostly college students, under the age of 30 yrs.

RESULTS

Overall, participants demonstrated increases in CRC knowledge and awareness after touring the inflatable colon (p-values < 0.001). Interestingly, both males and Hispanics had lower CRC awareness at pre-test, but exhibited maximum awareness gains equal to that of females and non Hispanic Whites after touring the IC. Behavioral intentions to obtain CRC screening in the future and to promote CRC awareness also increased (p-value < 0.001). Gender differences in behavioral intentions to act as advocators for CRC education were found (p < 0.05), with females being more likely to educate others about CRC than males.

CONCLUSION

Educational efforts conducted in early adulthood may serve to promote healthier lifestyles (e.g., physical activity, healthy nutrition, screening). These educated young adults may also serve to disseminate CRC information to high-risk friends and relatives. The walk through Inflatable Colon can increase CRC knowledge and intentions to get screened among a young and diverse population.

Age- and sex-specific spatio-temporal patterns of colorectal cancer mortality in Spain (1975-2008)

In this paper, space-time patterns of colorectal cancer (CRC) mortality risks are studied by sex and age group (50-69, ≥70) in Spanish provinces during the period 1975-2008. Space-time conditional autoregressive models are used to perform the statistical analyses. A pronounced increase in mortality risk has been observed in males for both age-groups. For males between 50 and 69 years of age, trends seem to stabilize from 2001 onward. In females, trends reflect a more stable pattern during the period in both age groups. However, for the 50-69 years group, risks take an upward trend in the period 2006-2008 after the slight decline observed in the second half of the period. This study offers interesting information regarding CRC mortality distribution among different Spanish provinces that could be used to improve prevention policies and resource allocation in different regions.

DNA methyltransferases: a novel target for prevention and therapy

Cancer is the second leading cause of death in US. Despite the emergence of new, targeted agents, and the use of various therapeutic combinations, none of the available treatment options are curative in patients with advanced cancer. Epigenetic alterations are increasingly recognized as valuable targets for the development of cancer therapies. DNA methylation at the 5-position of cytosine, catalyzed by DNA methyltransferases (DNMTs), is the predominant epigenetic modification in mammals. DNMT1, the major enzyme responsible for maintenance of the DNA methylation pattern is located at the replication fork and methylates newly biosynthesized DNA. DNMT2 or TRDMT1, the smallest mammalian DNMT is believed to participate in the recognition of DNA damage, DNA recombination, and mutation repair. It is composed solely of the C-terminal domain, and does not possess the regulatory N-terminal region. The levels of DNMTs, especially those of DNMT3B, DNMT3A, and DNMT3L, are often increased in various cancer tissues and cell lines, which may partially account for the hypermethylation of promoter CpG-rich regions of tumor suppressor genes in a variety of malignancies. Moreover, it has been shown to function in self-renewal and maintenance of colon cancer stem cells and need to be studied in several cancers. Inhibition of DNMTs has demonstrated reduction in tumor formation in part through the increased expression of tumor suppressor genes. Hence, DNMTs can potentially be used as anti-cancer targets. Dietary phytochemicals also inhibit DNMTs and cancer stem cells; this represents a promising approach for the prevention and treatment of many cancers.

Role of CIP2A in the antitumor effect of bortezomib in colon cancer

Cancerous inhibitor of protein phosphatase 2A (CIP2A) has been identified as an oncoprotein that is able to promote the proliferation of cancer cells. The role of CIP2A in the anticancer activity of bortezomib in colon cancer remains to be elucidated. In the present study, the antitumor effect of bortezomib was investigated and the role of CIP2A in determining the effect on colon cancer cells was identified. In the present study, bortezomib demonstrated an antitumor effect, as observed by WST‑1 assay and flow cytometry. In addition, the mRNA and protein level of CIP2A was inhibited in a dose‑dependent manner by bortezomib with quantitative PCR (qPCR) and western blotting. Furthermore, the inhibition of CIP2A with small interfering RNA by treatment with bortezomib inhibited proliferation, increased apoptosis and attenuated the invasion of the cells. Finally, the in vivo data demonstrated that bortezomib was able to decrease the growth of tumors, and that CIP2A was downregulated in the LoVo tumors treated with bortezomib. Therefore, CIP2A was shown to be important in the bortezomib‑induced inhibitory effect on colon cancer.

Overexpression of HOXB9 promotes metastasis and indicates poor prognosis in colon cancer

OBJECTIVE

Homeobox B9 (HOXB9) is proposed to be involved in tumor angiogenesis and metastasis. We investigated the role of HOXB9 in the progression of colon cancer.

METHODS

HOXB9 expression was investigated by immunohistochemically and Western blotting in 128 colon cancer patients and the results were analyzed statistically associated with clinicopathological data and survival of the patients. The effect of HOXB9 on cell invasion and metastases abilities were analyzed in vitro and in vivo.

RESULTS

HOXB9 is overexpressed in colon cancer tissues and significantly correlated with metastasis and poor survival of patients (P<0.05, respectively). Additionally, high levels of expression of HOXB9 were observed in metastatic lymph nodes. The down-regulation of HOXB9 expression can inhibit the migration and invasive ability of colon cancer cells, while exogenous expression of HOXB9 in colon cancer cells enhanced cell migration and invasiveness. Moreover, stable knockdown of HOXB9 reduced the liver and lung metastasis of colon cancer in vivo.

CONCLUSIONS

HOXB9 may play an important role in the invasion and metastasis of colon cancer cells and may be a useful biomarker for metastasis and prognostic of colon cancer.

Colorectal cancer statistics, 2014

Colorectal cancer is the third most common cancer and the third leading cause of cancer death in men and women in the United States. This article provides an overview of colorectal cancer statistics, including the most current data on incidence, survival, and mortality rates and trends. Incidence data were provided by the National Cancer Institute's Surveillance, Epidemiology, and End Results program and the North American Association of Central Cancer Registries. Mortality data were provided by the National Center for Health Statistics. In 2014, an estimated 71,830 men and 65,000 women will be diagnosed with colorectal cancer and 26,270 men and 24,040 women will die of the disease. Greater than one-third of all deaths (29% in men and 43% in women) will occur in individuals aged 80 years and older. There is substantial variation in tumor location by age. For example, 26% of colorectal cancers in women aged younger than 50 years occur in the proximal colon, compared with 56% of cases in women aged 80 years and older. Incidence and death rates are highest in blacks and lowest in Asians/Pacific Islanders; among males during 2006 through 2010, death rates in blacks (29.4 per 100,000 population) were more than double those in Asians/Pacific Islanders (13.1) and 50% higher than those in non-Hispanic whites (19.2). Overall, incidence rates decreased by approximately 3% per year during the past decade (2001-2010). Notably, the largest drops occurred in adults aged 65 and older. For instance, rates for tumors located in the distal colon decreased by more than 5% per year. In contrast, rates increased during this time period among adults younger than 50 years. Colorectal cancer death rates declined by approximately 2% per year during the 1990s and by approximately 3% per year during the past decade. Progress in reducing colorectal cancer death rates can be accelerated by improving access to and use of screening and standard treatment in all populations.

Reducing racial and ethnic disparities in colorectal cancer screening is likely to require more than access to care

Colorectal endoscopy, an effective screening intervention for colorectal cancer, is recommended for people age fifty or older, or earlier for those at higher risk. Rates of colorectal endoscopy are still far below those recommended by the US Preventive Services Task Force. This study examined whether factors such as the supply of gastroenterologists and the proportion of the local population without health insurance coverage were related to the likelihood of having the procedure, and whether these factors explained racial and ethnic differences in colorectal endoscopy. We found evidence that improving access to health care at the county and individual levels through expanded health insurance coverage could improve colorectal endoscopy use but might not be sufficient to reduce racial and ethnic disparities in colorectal cancer screening. Policy action to address these disparities will need to consider other structural and cultural factors that may be inhibiting colorectal cancer screening.

Changes in colorectal cancer incidence rates in young and older adults in the United States: what does it tell us about screening

PURPOSE

Colorectal cancer (CRC) incidence rates have increased among young adults and have decreased among older adults. We re-evaluated these trends using more recent data covering about 96 % of the United States population.

METHODS

Colorectal cancer incidence rates were abstracted from the National Program of Cancer Registries and the Surveillance Epidemiology and End Results analytic files for diagnosis years 1998-2009. We report rates for young adults (age <50 years) and for older adults (age 50 years or older) by four race/ethnicity groupings. We examined CRC incidence rates by stage at diagnosis, tumor subsite, and state. We calculated the correlation between state-specific CRC incidence and prevalence of colonoscopy reported in the Behavioral Risk Factor Surveillance System.

RESULTS

Rectal cancer incidence rates increased from 1998 through 2009 among young non-Hispanic white adults and young blacks. Among older adults, CRC incidence rates decreased among all four race/ethnicity groupings and in all states. The decline was apparent for all stages and for all subsites. States with greater decreases in CRC incidence rates had higher colonoscopy screening rates.

CONCLUSION

Rectal cancer is increasing among younger adults, for reasons largely unknown. Among older adults, CRC incidence continues to decrease, probably because of increasing uptake of colonoscopy screening. Decreases in CRC incidence are correlated with increased use of colonoscopy, indicating that CRC may be largely preventable through colonoscopy screening. Efforts to increase screening rates in underserved populations would help reduce health disparities associated with this type of cancer.

Screening for colorectal cancer: using data to set prevention priorities

INTRODUCTION

Adherence to colorectal cancer screening recommendations is known to vary by state, but less information is available about within-state variability. In the current study, we assess county-level screening rates for Missouri, with the goal of better targeting public health efforts to increase screening.

METHODS

Prevalence of colorectal cancer screening among Missouri adults between the ages of 50 and 74 was obtained from 2008 and 2010 Behavioral Risk Factor Surveillance System data. We used multilevel logistic regression to generate county-specific estimates. After excluding 77 counties with fewer than 30 respondents, information was available about 3,739 individuals in 37 counties, representing 78.5 % of the state population.

RESULTS

Across counties, the prevalence of being up-to-date with recommended colorectal cancer screening ranged from 25 to 70 %.

CONCLUSION

State-level information about colorectal cancer screening masks substantial within-state variability. Assessing and monitoring county-level disparities in screening can guide public health efforts to increase screening and reduce colorectal cancer mortality. More complete population survey data will make such analysis possible.