Race and Medicine

Race and Medicine

Issue: January, 2021
Disclosures: Jain reports no relevant financial disclosures. Gadi reports no relevant financial disclosures. Henderson reports no relevant financial disclosures.
January 25, 2021
6 min read
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Should OTC colorectal cancer screening tests be usual care for young Black individuals?

Issue: January, 2021
Disclosures: Jain reports no relevant financial disclosures. Gadi reports no relevant financial disclosures. Henderson reports no relevant financial disclosures.
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POINT

Recommending over-the-counter colorectal cancer screening tests for young Black individuals ultimately may save lives.

Although colorectal cancer is most commonly diagnosed among those aged older than 50 years, we have seen a decrease in cases diagnosed in that age group due to screening and prevention. Unfortunately, the rates of colorectal cancer among those aged younger than 50 years have been rising in the United States, with an estimated 12% of cases, or about 18,000, diagnosed among this younger population in 2020. Recently, the American Cancer Society and the USPSTF lowered the recommended age to begin screening to 45 years.

Shikha Jain, MD, FACP
Shikha Jain

Individuals in Black communities are affected at higher rates than any other racial and ethnic group in the U.S. — they are 20% more likely to be diagnosed and 40% more likely to die of colorectal cancer than most other groups. In 2019, almost 20,000 cases of colorectal cancer were diagnosed in Black individuals, who are also more likely to develop colorectal cancer at a younger age and at a more advanced stage when diagnosed. There are many complex reasons for these disparities, some of which include risk factors, environmental exposures and barriers to care.

Regular screening, such as with fecal occult blood tests, colonoscopies and sigmoidoscopies, contribute to the prevention of colorectal cancer and also result in the diagnosis of cancers at an early stage and improved overall outcomes. For patients who are at highest risk, such as individuals in our Black communities, providing an easily accessible screening test for colon cancer detection, available at the local grocery store or pharmacy, may be one way to try to capture more of these early-stage cancers in younger populations. By addressing the access-to-care barrier, this recommendation also provides an effective way to increase detection of colorectal cancer in those patients who otherwise may not be following up regularly with a physician.

Research has shown that men in general do not see their doctors regularly. For Black individuals, this is compounded by a mistrust of the health care system that stems from centuries of discrimination and exploitation of Black Americans by U.S. medical institutions. With the increased risk for a colorectal cancer diagnosis among Black individuals, and the increase in the number of young people diagnosed, recommending OTC tests for colorectal cancer detection may address one major hurdle of diagnosing cancers in this population: access to care. Additionally, for those who do not qualify for standard-of-care screening modalities such as colonoscopies due to their age, or lack of insurance or other barriers to care, this methodology may allow the capture of colorectal cancer in this at-risk population that otherwise would be missed.

References:

American Cancer Society. Colorectal cancer rates higher in African Americans, rising in younger people. Available at: https://www.cancer.org/latest-news/colorectal-cancer-rates-higher-in-african-americans-rising-in-younger-people.html. Accessed Jan. 11, 2021.

NCI. Survival disparities identified in young African Americans with colorectal cancer. Available at: https://www.cancer.gov/news-events/cancer-currents-blog/2016/colorectal-survival-disparities. Accessed Jan. 11, 2021.

Cimons M. Many men avoid doctors. That can be dangerous, even deadly, for them. Washington Post. April 12, 2020. Available at: https://www.washingtonpost.com/health/many-men-avoid-doctors-that-can-be-dangerous-even-deadly-for-them/2020/04/10/ffab50d0-7824-11ea-a130-df573469f094_story.html. Accessed Jan. 11, 2021.

USPSTF. Draft Recommendation Statement, Colorectal Cancer Screening. Available at: https://uspreventiveservicestaskforce.org/uspstf/draft-recommendation/colorectal-cancer-screening3#fullrecommendationstart. Accessed Jan. 11, 2021.

Wells L and Gowda A. A Legacy of Mistrust: African Americans and the US Healthcare System. Proceedings of UCLA Health. 2020 Volume 24.

Shikha Jain, MD, FACP, is an assistant professor of internal medicine, director of diagnostic bone marrow services and co-director of the benign hematology program at Rush University Medical Center. She also is a HemOnc Today Editorial Board Member, the Consulting Medical Editor for Healio’s Women in Oncology and the host of Healio’s Oncology Overdrive podcast. She can be reached at sjain25@uic.edu and on Twitter @ShikhaJainMD.

COUNTER

Not quite yet.

Recent trends show that colorectal cancer incidence is increasing among adults aged younger than 50 years, and Black adults have the highest colorectal cancer incidence and mortality rates compared with other races and ethnicities in the U.S. among all age groups. These trends suggest the need to revisit screening guidelines now or soon.

VK Gadi, MD, PhD
VK Gadi
Vida Henderson, PhD, PharmD, MPH, MFA
Vida Henderson

Colorectal cancer disparities are attributed to differences in screening access, screening follow-up and underlying risk factors. Although stool-based screening tests are shown to reduce colorectal cancer mortality among average-risk adults, no studies support the effectiveness and accuracy of these tests for adults aged younger than 50 years. Additionally, colorectal cancer disparities are attributed to a complex web of multilevel factors, and there is insufficient evidence to suggest that OTC colorectal cancer screening tests would result in decreases in colorectal cancer mortality among young Black adults.

Currently available point-of-care, stool-based colorectal cancer screening tests include guaiac-based fecal occult blood tests, fecal immunochemical tests and stool DNA tests. Of note, stool DNA tests, such as Cologuard (Exact Sciences), are available only by prescription from a health care provider. Although pooled sensitivity and specificity for detecting colorectal cancer among stool-based tests are moderate to high, they may not be high enough to screen a population such as young Black individuals, among whom the pretest probability for colorectal cancer remains low compared with average-risk older individuals.

Widespread adoption of testing for the endpoint of colorectal cancer detection may result in reduced accuracy of the test and high rates of false positives. Moreover, screening tests that detect and remove adenomas are most reliable for preventing the development of colorectal cancer. Sensitivity for detecting adenomas is much lower for stool-based tests compared with colonoscopy, which enables the detection and removal of adenomas simultaneously.

Stool-based colorectal cancer screening tests are recommended only for individuals at average risk. Without proper risk assessment, high-risk individuals may not get proper screening necessary for early detection and prevention of colorectal cancer, and OTC colorectal cancer screening may perpetuate late detection and diagnosis among higher-risk populations. Further, if abnormal results are detected with point-of-care colorectal cancer screening, diagnostic follow-up may prove more difficult for individuals without an established provider or health care home.

Black adults aged younger than 65 years are less likely to have health insurance compared with their white counterparts, and individuals without health insurance are less likely to engage in colorectal cancer screening. Although OTC screening may be more accessible to uninsured and underinsured individuals, paying for diagnostic follow-up services may not be possible or pose financial hardships for some.

Stool-based tests may be perceived as more convenient because they require no bowel prep, are less invasive and the sampling can be conducted at home. However, these tests must be conducted annually or every 3 years; less frequent testing with colonoscopy — every 10 years with normal results — may align with better adherence and may be more convenient for patients who do not routinely access health care. Point-of-care colorectal cancer screening without direct provider involvement may not increase screening utilization or adherence among young Black adults, as expected. Studies showed that receiving a provider recommendation and having a usual source of care are strong predictors of colorectal cancer screening utilization, and individuals who discuss colorectal cancer screening with their provider are more likely to be up to date on screening.

For these reasons, the recommendation for young Black individuals to use OTC screening tests for colorectal cancer may backfire and erode trust in screening overall. Further studies are needed to test the clinical effectiveness of and community-based interventions with stool-based colorectal cancer screening for young Black adults before widespread OTC access is available. Only then could we be convinced to answer yes to the question posed.

References:

Carethers JM and Doubeni CA. Gastroenterology. 2020;doi:10.1053/j.gastro.2019.10.029.

Gupta S, et al. J Natl Cancer Inst. 2014;doi:10.1093/jnci/dju032.

Imperiale TF, et al. Ann Intern Med. 2019;doi:10.7326/M18-2390.

Lin JS, et al. JAMA. 2016;doi:10.1001/jama.2016.3332.

Rutter CM, et al. Cancer Epidemiol Biomarkers Prev. 2020;doi:10.1158/1055-9965.EPI-19-1537.

USPSTF. Draft Recommendation Statement, Colorectal Cancer Screening. https://uspreventiveservicestaskforce.org/uspstf/draft-recommendation/colorectal-cancer-screening3#fullrecommendationstart. Accessed Jan. 11, 2020.

Virostko J, et al. Cancer. 2019;doi:10.1002/cncr.32347.

VK Gadi, MD, PhD, is a professor and director of medical oncology at University of Illinois at Chicago. He can be reached at vkgadi@uic.edu. Vida Henderson, PhD, PharmD, MPH, MFA, is a senior research scientist and director of the Community Engagement and Health Equity office at University of Illinois Cancer Center. She can be reached at vhende5@uic.edu.