1. Colorectal cancer: How do we approach health disparities? Marta L. Davila, MD, FASGE University of Texas MD Anderson Cancer Center

2. Colorectal cancer (CRC) Facts Third most common cause of cancer Second leading cause of cancer- related deaths in men and women in the US An estimated 143,000 cases of CRC are expected to occur in 2012 American Cancer Society. Cancer facts and figures 2012. Atlanta: American Cancer Society; 2012

3. Colorectal cancer Facts 51, 690 deaths from CRC are expected to occur in 2012 Americans have a 5% lifetime risk for CRC Rare before age 40 in both men and women, with 90% of cases occurring after age 50

4. Colorectal cancer Facts Incidence of CRC has been declining in the US by 2-3% per year over the last 15 years CRC screening probably accounts for this decline by early detection and removal of polyps Good evidence shows that screening reduces mortality from CRC

5. Polyp to Cancer Progression Figure available at: http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease3&organ=6&disease=36&lang_id=1. Accessed March 18, 2009. A. Sessile polypB. Pedunculated polyp C. Colon cancer

6. Colorectal cancer Facts Modifiable factors associated with increased risk of CRC: Obesity Physical inactivity Diet high in red or processed meat Alcohol consumption Long-term smoking Low intake of fruits and vegetables Early identification of patients with genetic conditions

7. Cancer health disparities Definition: “..adverse differences noted in cancer epidemiology that exist among specific groups in the U.S.” Further defined by new cases (incidence), deaths (mortality) and associated psychosocial and financial burden These populations are characterized by age, education, ethnicity/race, gender, income and geographic location

8. Cancer disparities Causes Social Economic Cultural Health system factors Inequities in work, wealth, education, housing, and barriers to prevention, early detection and treatment services

9. American Cancer Society. Colorectal Cancer Facts and Figures. 2011-2013 Atlanta: American Cancer Society. 2011

10. American Cancer Society. Colorectal Cancer Facts and Figures. 2011-2013 Atlanta: American Cancer Society. 2011

11. CRC disparities African-Americans Dietary / Nutritional factors Rates of physical inactivity Variability in screening rates Lower use of diagnostic testing Decreased access to high-volume hospitals and subspecialists Genetic susceptibilities Cancer biology

13. American Cancer Society. Colorectal Cancer Facts and Figures. 2011-2013 Atlanta: American Cancer Society. 2011

14. Colorectal cancer screening guidelines

15. CRC screening guidelines US Preventive Services Task Force (USPSTF) For average-risk adults, screening should begin at age 50 and continue until age 75 CRC screening in adults 76 to 85 years should be individualized Ann Intern Med 2008;149:627-37

16. CRC screening guidelines American Cancer Society (ACS), US Multi-society Task Force on Colorectal Cancer (USMSTF) and the American College of Radiology (ACR) TestTime interval Flexible sigmoidoscopy5 years Optical colonoscopy10 years Double-contrast barium enema5 years CT colonography5 years Fecal occult blood test (guaiac or immunochemical based) Annual Stool DNA testUncertain Average-risk adult should start screening at age 50 Ann Intern Med 2012;156:378-386

18. American Cancer Society. Colorectal Cancer Facts and Figures. 2011-2013 Atlanta: American Cancer Society. 2011

19. CRC screening Barriers Cost and lack of access to health care Physician variability regarding screening recommendations Poor transmission of the benefits and risks of not getting screened Personal barriers Fear, embarrassment, distrust of the medical community

20. Strategies to increase CRC screening Prompt one-on-one discussion about the potentially life-saving importance of screening Remove financial barriers to screening Help patients navigate through the healthcare system Use educational prompts to educate the community about Colonoscopy and other forms of screening

21. Strategies to reduce CRC disparities Support increased funding for colorectal cancer programs and research at the NIH Support the CDC Colorectal cancer Control Program Goal: to increase CRC screening rates in adults >50 years to 80% Support community programs targeting racial/ethnic minorities

22. Summary Colorectal Cancer is a common, yet preventable disease that affects 140,000 individuals annually Colorectal Cancer mortality has declined over the past 3 decades largely due to increased screening Disproportionately higher cancer incidence and mortality rates in minority populations may be directly related to barriers to screening Identifying these barriers is key to improved outcomes