Colorectal cancer disparities beyond biology Screening treatment access

Socioeconomic status on survival outcomes in patients with colorectal cancer: a cross-sectional study

BACKGROUND

Colorectal cancer (CRC) is widely acknowledged as a prevalent malignancy and the second most common cause of cancer-related mortality worldwide. The aim of this study was to examine the independent impact of Median Household Income (MHI) on prognosis and survival outcomes in patients with CRC.

METHODS

Data from 17 cancer registries of the United States Surveillance, Epidemiology, and End Results program, with follow-up extended until November 2022 was analyzed. A Cox proportional hazards regression analysis was conducted to evaluate the influence of different levels of MHI on survival outcomes among patients with CRC. A total of 761,697 CRC patient records were retrieved from the SEER database.

RESULTS

The Cox regression analysis results indicated that patients with higher MHI exhibited improved overall survival outcomes when compared to those with lower MHI (MMHI: P < 0.001; HMHI: P < 0.001). Regardless of the specific tumor location, gender, stage of CRC, or treatment method, higher MHI is consistently linked to improved survival outcomes. However, this association was not found to be statistically significant among American Indian/Alaska Native (MMHI: P = 0.017; HMHI: P = 0.081), Asian or Pacific Islander (MMHI: P = 0.223; HMHI: P = 0.002) and unmarried or domestic partner patients (MMHI: P = 0.311; HMHI: P = 0.011).

CONCLUSION

These results emphasize the importance of considering socioeconomic factors, such as income level, in understanding and addressing disparities in survival outcomes of CRC patients.

A Multi-Omics Overview of Colorectal Cancer to Address Mechanisms of Disease, Metastasis, Patient Disparities and Outcomes

Human colorectal cancer (CRC) is one of the most common malignancies in men and women across the globe, albeit CRC incidence and mortality shows a substantial racial and ethnic disparity, with the highest burden in African American patients. Even with effective screening tools such as colonoscopy and diagnostic detection assays, CRC remains a substantial health burden. In addition, primary tumors located in the proximal (right) or distal (left) sides of the colorectum have been shown to be unique tumor types that require unique treatment schema. Distal metastases in the liver and other organ systems are the major causes of mortality in CRC patients. Characterizing genomic, epigenomic, transcriptomic and proteomic (multi-omics) alterations has led to a better understanding of primary tumor biology, resulting in targeted therapeutic advancements. In this regard, molecular-based CRC subgroups have been developed that show correlations with patient outcomes. Molecular characterization of CRC metastases has highlighted similarities and differences between metastases and primary tumors; however, our understanding as to how to improve patient outcomes based on metastasis biology is lagging and remains a major obstacle to improving CRC patient outcomes. In this review, we will summarize the multi-omics features of primary CRC tumors and their metastases across racial and ethnic groups, the differences in proximal and distal tumor biology, molecular-based CRC subgroups, treatment strategies and challenges for improving patient outcomes.

Immunohistochemical Expression of Glutathione Peroxidase 1 (Gpx-1) as an Independent Prognostic Factor in Colon Adenocarcinoma Patients

Several studies revealed that expression levels of glutathione peroxidase 1 (Gpx-1) can be associated with cancer development, mainly through its role in hydroperoxide scavenging by regulating intracellular reactive oxygen species (ROS) levels. Therefore, our aim was to investigate the expression of Gpx-1 protein in a population of Polish patients with colon adenocarcinoma in the absence of any therapy prior to radical surgery. The study was carried out using colon tissue from patients with adenocarcinoma of the colon confirmed by histopathological examination. Gpx-1 antibody was used to determine the immunohistochemical expression of Gpx-1. The Chi²test or Chi²_Yatesa test were used to analyse the associations between the immunohistochemical expression of Gpx-1 and clinical parameters. The relationship between Gpx-1 expression, and 5-year patient survival was examined using Kaplan-Meier analysis and the log-rank test. Intracellular localisation of Gpx-1 was detected by the use of transmission electron microscopy (TEM). Western blot analysis was used for the evaluation of Gpx-1 protein expression levels in cancer cell lines in vitro. Immunohistochemical study revealed that the high expression of Gpx-1 was associated with the tumour's histological grade, proliferating cell nuclear antigen (PCNA) immunohistochemical expression, depth of invasion, and angioinvasion (all p < 0.001) (4). The high immunohistochemical expression of Gpx-1 is correlated with poor prognosis of colon adenocarcinoma patients.

The Clinical Application of Immunohistochemical Expression of Notch4 Protein in Patients with Colon Adenocarcinoma

The Notch signalling pathway is one of the most conserved and well-characterised pathways involved in cell fate decisions and the development of many diseases, including cancer. Among them, it is worth noting the Notch4 receptor and its clinical application, which may have prognostic value in patients with colon adenocarcinoma. The study was performed on 129 colon adenocarcinomas. Immunohistochemical and fluorescence expression of Notch4 was performed using the Notch4 antibody. The associations between the IHC expression of Notch4 and clinical parameters were analysed using the Chi² test or Chi²_Yatesa test. The Kaplan-Meier analysis and the log-rank test were used to verify the relationship between the intensity of Notch4 expression and the 5-year survival rate of patients. Intracellular localisation of Notch4 was detected by the use of the immunogold labelling method and TEM. 101 (78.29%) samples had strong Notch4 protein expression, and 28 (21.71%) samples were characterised by low expression. The high expression of Notch4 was clearly correlated with the histological grade of the tumour (p < 0.001), PCNA immunohistochemical expression (p < 0.001), depth of invasion (p < 0.001) and angioinvasion (p < 0.001). We can conclude that high expression of Notch4 is correlated with poor prognosis of colon adenocarcinoma patients (log-rank, p < 0.001).

"As a clinician, you have to be passionately involved": Advocacy and professional responsibility in gender-affirming healthcare

Previous research has studied how clinicians such as physicians, nurses, social workers, and nutritionists understand advocacy as a professional responsibility. Analyses have typically focused on individual healthcare professions and have viewed ambiguity around the conceptualization of advocacy as detrimental. Little research has considered how multiple professions within a single field of healthcare interpret clinician advocacy, nor how ambiguity might be productive in a multidisciplinary field. This article addresses these gaps by utilizing science and technology studies scholarship on buzzwords to analyze how clinicians in the field of gender-affirming healthcare have come to understand advocacy as a professional responsibility despite significant ambiguity around the goals, tactics, and targets of advocacy. Gender-affirming healthcare refers to any kind of physical or mental healthcare that transgender and gender diverse (TGD) people obtain to affirm their gender identity. Drawing on interviews with 30 U.S. clinicians, observation of nine transgender health conferences, and content analysis of 202 professional journal articles and 11 professional association statements, I argue that ambiguity around advocacy has been key to its uptake as a responsibility across multiple professions in this field. Foregrounding interview data, I show how polysemy allows clinician respondents across professions to reassert their expertise as they delineate what constitutes good gender-affirming healthcare and defend the emergent field in three problem domains: health insurance, the marginalization of TGD people, and the legality of gender-affirming healthcare. I also demonstrate how theoretical work on buzzwords explains why three clinician respondents rejected advocacy as a professional responsibility.

The global, regional, and national burden and quality of care index (QCI) of colorectal cancer; a global burden of disease systematic analysis 1990-2019

Background

Colorectal cancer (CRC) is among the five most incident and lethal cancers in world and its burden varies between countries and sexes. We aimed to present a comprehensive measure called the quality of care index (QCI) to evaluate the inequity and healthcare quality of care regarding CRC by sex and location.

Methods

Data on the burden of CRC were extracted from the Global Burden of Disease study 2019. It was transformed to four ratios, including mortality-to-incidence, disability-adjusted life years (DALYs)-to-prevalence, prevalence-to-incidence, and years of life lost (YLLs)-to-years lived with disability (YLDs). Principal component analysis was implemented on the four ratios and the most influential component was considered as QCI with a score ranging from zero to 100, for which higher scores represented better quality of care. Gender Disparity Ratio (GDR) was calculated by dividing QCI for females by males.

Results

The global incidence and death numbers of CRC were 2,166,168 (95% uncertainty interval: 1,996,298–2,342,842) and 1,085,797 (1,002,795–1,149,679) in 2019, respectively. Globally, QCI and GDR values were 77.6 and 1.0 respectively in 2019. There was a positive association between the level of quality of care and socio-demographic index (SDI) quintiles. Region of the Americas and African Region had the highest and lowest QCI values, respectively (84.4 vs. 23.6). The QCI values started decreasing beyond the age of 75 in 2019 worldwide.

Conclusion

There is heterogeneity in QCI between SDI quintiles. More attention should be paid to people aged more than 75 years old because of the lower quality of care in this group.

The Impact of Income and Social Mobility on Colorectal Cancer Outcomes and Treatment: A Cross-sectional Study

OBJECTIVE

To determine the impact of income mobility on racial disparities in colorectal cancer.

BACKGROUND

There are well-documented disparities in colorectal cancer treatment and outcomes between Black and White patients. Socioeconomic status, insurance, and other patient-level factors have been shown important, but little has been done to show the discriminatory factors that lead to these outcomes.

METHODS

Data were obtained from the Surveillance Epidemiology and End-Results database for Black and White patients with colorectal cancer between 2005 and 2015. County level measures of Black (BIM) and White income mobility (WIM) were obtained from the Opportunity Atlas as a measure of intergenerational poverty and social mobility. Regression models were created to assess the relative risk of advanced stage at diagnosis (Stage IV), surgery for localized disease (Stage I/II), and cancer-specific mortality.

RESULTS

There was no significant association of BIM or WIM on advanced stage at diagnosis in Black or White patients. An increase of $10,000 of BIM was associated with a 9% decrease in hazards of death for both Black (hazard ratio 0.91, 95% confidence interval 0.86,0.95) and White (0.91, 95%CI 0.90,0.93) patients, while the same increase in WIM was associated with no significant difference in hazards among Black patients (hazard ratio 0.99, 95% confidence interval 0.97,1.02). There were no predicted racial differences in hazards of death at high levels of BIM.

CONCLUSIONS

Increased Black income mobility significantly improves survival for both Black and White patients. Interventions aimed at increasing economic and social mobility could significantly decrease mortality in both Black and White patients while alleviating disparities in outcomes.

The association of health insurance and race with treatment and survival in patients with metastatic colorectal cancer

Background

Black patients and underinsured patients with colorectal cancer (CRC) present with more advanced disease and experience worse outcomes. The study aim was to evaluate the interaction of health insurance status and race with treatment and survival in metastatic CRC.

Materials and methods

Patients diagnosed with metastatic CRC within NCDB from 2006–2016 were included. Primary outcomes included receipt of chemotherapy and 3-year all-cause mortality. Multivariable logistic regression and Cox-regression (MVR) including a two-way interaction term of race and insurance were performed to evaluate the differential association of race and insurance with receipt of chemotherapy and mortality, respectively.

Results

128,031 patients were identified; 70.6% White, 14.4% Black, 5.7% Hispanic, and 9.3% Other race. Chemotherapy use was higher among White compared to Black patients. 3-year mortality rate was higher for Blacks and lower for Hispanics, in comparison with White patients. By MVR, Black patients were less likely to receive chemotherapy. When stratified by insurance status, Black patients with private and Medicare insurance were less likely to receive chemotherapy than White patients. All-cause mortality was higher in Black patients and lower in Hispanic patients, and these differences persisted after controlling for insurance and receipt of chemotherapy.

Conclusion

Black patients and uninsured or under-insured patients with metastatic CRC are less likely to receive chemotherapy and have increased mortality. The effect of health insurance among Blacks and Whites differs, however, and improving insurance alone does not appear to fully mitigate racial disparities in treatment and outcomes.

Calling Attention to the Role of Race-Driven Societal Determinants of Health on Aggressive Tumor Biology: A Focus on Black Americans

Blacks have the highest incidence and mortality from most cancers. The reasons for these disparities remain unclear. Blacks are exposed to adverse social determinants because of historic and contemporary racist polices; however, how these determinants affect the disparities that Blacks experience is understudied. As a result of discriminatory community policies, like redlining, Blacks have higher exposure to air pollution and neighborhood deprivation. Studies investigating how these factors affect tumor biology are emerging. We highlight the literature that connects racism-related community exposure to the tumor biology in breast, lung, prostate, and colorectal cancer. Further investigations that clarify the link between adverse social determinants that result from systemic racism and aggressive tumor biology are required if health equity is to be achieved. Without recognition that racism is a public health risk with carcinogenic impact, health care delivery and cancer care will never achieve excellence. In response, health systems ought to establish corrective actions to improve Black population health and bring medical justice to marginalized racialized groups.

Racial Disparities in the Management of Locoregional Colorectal Cancer

Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.

A qualitative study of patient preferences for prompts and reminders for a direct-mail fecal testing program

Programs that directly mail fecal immunochemical tests (FIT) to patients can increase colorectal cancer (CRC) screening, especially in low-income and Latino populations. Few studies have explored patient reactions to prompts or reminders that accompany such programs. As part of the Participatory Research to Advance Colon Cancer Prevention pilot study, which tested prompts and reminders to a direct-mail FIT program in a large, urban health center, we conducted telephone interviews among English- and Spanish-speaking participants who were assigned to receive a series of text message prompts, automated phone call reminders, and/or live phone call reminders. We analyzed interviews using a qualitative content analysis approach. We interviewed 41 participants, including 25 responders (61%) and 16 nonresponders (39%) to the direct-mail program. Participants appreciated program ease and convenience. Few participants recalled receiving prompts or automated/live reminders; nevertheless, the vast majority (95%, n = 39) thought reminders were acceptable and helpful and suggested that 2-3 reminders delivered starting 1 week after the mailed FIT would optimally encourage completion. Prompts and reminders used with mailed-FIT programs are accepted by patients, and my help boost response rates.

Barriers Driving Racial Disparities in Colorectal Cancer Screening in African Americans

PURPOSE OF REVIEW

Colorectal cancer screening has been shown to decrease mortality from colorectal cancer. Screening disparities continue to exist among ethnic minorities, particularly for African Americans. We herein review the barriers of colorectal cancer screening in this population.

RECENT FINDINGS

At its foundation are patient barriers, which are further compounded by physician-related barriers and the idiosyncrasies of the healthcare system. Interventions to address the barriers include patient outreach, provider education, and healthcare legislation addressing financial barriers. Recent research has focused on factors predicting intentions to undergo colorectal cancer screening. Underlying all of the barriers is the systemic racism that affects and influences the healthcare system as much as all other institutions and contributes to inequities in the delivery of effective cancer prevention efforts. Perpetual disparities in CRC screening within the African American community are due to multifactorial barriers from the individual patient to provider and healthcare system and societal influences. An awareness of the behavioral and systemic factors that affect African Americans must underpin efforts to reach full equity in delivering CRC screening to this often medically underserved segment of our society.

Updated Assessment of Colorectal Cancer Incidence in the U.S. by Age, Sex, and Race/Ethnicity

BACKGROUND

Whether recent updates to colon cancer screening guidelines benefit men and women or all race/ethnic groups equally is not clear.

AIMS

The aim of this study is to evaluate age-, sex-, and race/ethnicity-specific trends in CRC incidence and disease burden among adults.

METHODS

Using 2000-2014 surveillance, epidemiology, and end results database, annual CRC incidence (per 100,000 persons/year) among U.S. adults was categorized by age (using 10-year age intervals) and stratified by sex and race/ethnicity. Comparison of incidence between groups utilized the z-statistic with p < 0.05 indicating statistical significance.

RESULTS

Overall, CRC incidence was the highest among patients aged ≥ 80 years (330.8 per 100,000 persons/year), which was significantly higher in men versus women (377.2 vs. 304.3 per 100,000 persons/year, p < 0.001). CRC incidence in younger individuals was 22.8 per 100,000 persons/year (age 40-49) and 6.8 per 100,000 persons/year (age 30-39). CRC incidence was significantly higher in African Americans compared to non-Hispanic whites. From 2000 to 2014, CRC incidence declined in all age groups over age 60, remained stable in age 50-59, and demonstrated proportional increases in among age 20-49 years. While CRC incidence in all race/ethnic groups aged ≥ 60 years declined, Hispanics aged 50-59 increased 21.9%, but remained stable in other race/ethnic groups. Race/ethnicity-specific disparities in CRC incidence in patients aged 20-49 were also observed.

CONCLUSIONS

While CRC incidence has declined among U.S. adults aged ≥ 60, increasing incidence among patients aged < 50 is concerning. Identifying risk factors among "average-risk" patients is needed to better implement targeted screening of individuals not currently meeting CRC screening criteria.

Racial differences in brain cancer characteristics and survival: an analysis of SEER data

PURPOSE

Racial disparity with shorter survival for Blacks than Whites is well known for many cancers. However, for brain cancer, some national cancer registry studies have shown better survival among Blacks compared to Whites. This study aimed to systematically investigate whether Blacks and Whites differ in survival and also in tumor characteristics and treatment for neuroepithelial brain tumors.

METHODS

The National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database was used to identify non-Hispanic White and Black patients diagnosed with malignant, histologically confirmed neuroepithelial brain cancer from 2004 through 2015. Racial differences in brain cancer survival were compared using Kaplan-Meier curve and Cox proportional hazard models. The associations of race with tumor and treatment characteristics (location, size, grade, surgical type) were examined using multinomial logistic regression.

RESULTS

After adjusting for demographic, tumor, and treatment factors, there were no significant differences in survival for non-Hispanic Blacks compared to non-Hispanic Whites [hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.99-1.10]. Non-Hispanic Blacks had higher odds of being diagnosed with tumors of unknown grade [odds ratio (OR) 1.16, 95% CI 1.05-1.29], unknown size (OR 1.14, 95% CI 1.01-1.29), infratentorial (OR 1.12, 95% CI 1.01-1.24) or overlapping area (OR 1.39, 95% CI 1.14-1.70), and lower odds of having a total surgical resection (OR 0.83, 95% CI 0.74-0.93).

CONCLUSION

Non-Hispanic Blacks do not exhibit longer brain cancer-specific survival than non-Hispanic Whites. They were more likely to have tumors of unknown size or grade and less likely to receive total surgical resection, which may result from racial differences in access to and use of healthcare.

Costs of Cancer Care Across the Disease Continuum

Using SEER‐Medicare data, this article demonstrates that considerable differences exist in expenditures across phases of care and varying patient characteristics. These findings can help to provide a better understanding of the drivers of payment variation across patient and tumor characteristics to inform efforts to decrease costs and increase quality of cancer care.

Purpose.

The aim of this study was to estimate Medicare payments for cancer care during the initial, continuing, and end‐of‐life phases of care for 10 malignancies and to examine variation in expenditures according to patient characteristics and cancer severity.

Materials and Methods.

We used linked Surveillance, Epidemiology and End Results‐Medicare data to identify patients aged 66–99 years who were diagnosed with one of the following 10 cancers: prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian, from 2007 through 2012. We attributed payments for each patient to a phase of care (i.e., initial, continuing, or end of life), based on time from diagnosis until death or end of study interval. We summed payments for all claims attributable to the primary cancer diagnosis and analyzed the overall and phase‐based costs and then by differing demographics, cancer stage, geographic region, and year of diagnosis.

Results.

We identified 428,300 patients diagnosed with one of the 10 malignancies. Annual payments were generally highest during the initial phase. Mean expenditures across cancers were $14,381 during the initial phase, $2,471 for continuing, and $13,458 at end of life. Payments decreased with increasing age. Black patients had higher payments for four of five cancers with statistically significant differences. Stage III cancers posed the greatest annual cost burden for four cancer types. Overall payments were stable across geographic region and year.

Conclusion.

Considerable differences exist in expenditures across phases of cancer care. By understanding the drivers of such payment variations across patient and tumor characteristics, we can inform efforts to decrease payments and increase quality, thereby reducing the burden of cancer care.

Implications for Practice.

Considerable differences exist in expenditures across phases of cancer care. There are further differences by varying patient characteristics. Understanding the drivers of such payment variations across patient and tumor characteristics can inform efforts to decrease costs and increase quality, thereby reducing the burden of cancer care.

Tetrac-conjugated polymersomes for integrin-targeted delivery of camptothecin to colon adenocarcinoma in vitro and in vivo

In this study, we prepared tetraiodothyroacetic acid (tetrac) conjugated PEG-PLGA polymersomes for the targeted delivery of camptothecin to colon adenocarcinoma. Tetrac, which binds to integrin α_vβ₃ with high affinity and specificity, was covalently conjugated to the surface of the PEGylated polymersomal formulation of camptothecin (CPT). The hydrodynamic and morphological properties of the prepared system were evaluated using TEM (transmission electron microscopy), SEM (scanning electron microscopy) and DLS (dynamic light scattering) experiments. Camptothecin was encapsulated in the polymersomal system with encapsulation efficiency and loading content of 84±10.12 and 4.2±0.82, respectively. The in vitro release profile of camptothecin from the polymersomal formulation revealed the sustained release pattern. In vitro cytotoxicity experiments confirmed that the tetrac-conjugated camptothecin loaded-polymersomes had higher cellular toxicity towards integrin-overexpressed HT29 and C26 colorectal cancer cells than integrin-negative CHO cell line. The in vivo tumor inhibitory effect of tetrac-conjugated camptothecin loaded-polymersomes demonstrated an enhanced therapeutic index of integrin targeted polymersomal formulation over both non-targeted polymersomal formulation and free camptothecin in C26 tumor bearing mice. The obtained results demonstrated that the prepared tetrac-conjugated polymersomes were able to control the release of camptothecin, and significantly increase the therapeutic index of compthotecin. This study demonstrates the versatility of integrin-targeted tetrac-conjugated PEG-PLGA polymersomal formulation as an anti-cancer nano-pharmaceutical platform.

Smart AS1411-aptamer conjugated pegylated PAMAM dendrimer for the superior delivery of camptothecin to colon adenocarcinoma in vitro and in vivo

In the current study camptothecin-loaded pegylated PAMAM dendrimer were synthesized and were functionalized with AS1411 anti-nucleolin aptamers for site-specific targeting against colorectal cancer cells which over expresses nucleolin receptors. The morphological properties and size dispersity of the prepared nanoparticles were evaluated using transmission electron microscope (TEM) and DLS. The drug-loading content and encapsulation efficiency were obtained 8.1% and 93.67% respectively. The in vitro release of camptothecin from the formulation was provided the sustained release of encapsulated camptothecin during 4days. Comparative in vitro cytotoxicity experiments demonstrated that the targeted camptothecin loaded-pegylated dendrimers had higher antiproliferation activity, towards nucleolin-positive HT29 and C26 colorectal cancer cells than nucleolin-negative CHO cell line. Fluorscence microscopy and flow cytometry also confirmed the enhanced cellular uptake of AS1411 targeted pegylated-dendrimer. In vivo study in C26 tumor-bearing BALB/C mice revealed that the AS1411-functionalized camptothecin loaded pegylated dendrimers improved antitumor activity and survival rate of the encapsulated camptothecin. Conjugation of AS1411 aptamer to the camptothecin loaded-pegylated dendrimer surface provides site-specific delivery of camptothecin, inhibit C26 tumor growth in vivo and significantly decrease systemic toxicity. These results suggested that the new nucleolin-targeted pegylated PAMAM dendrimer as a delivery system for camptothecin have the potential for the treatment of nucleolin-overexpressed colorectal cancer.