Volume 1, Issue 2

 

Disparities in Colon Cancer among an African American Population at a Community Hospital in Brooklyn.

August 16, 2010

 

Introduction:

Each year approximately 148,810 new cases of colorectal cancer are diagnosed and nearly 50,000 people die from the disease.[1] Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States and accounts for 15% of all cancers diagnosed annually.  Early diagnosis is closely related to survival.  Five-year survival exceeds 90% for patients diagnosed with disease localized to the colon or rectum compared with only 60% for patients with regional lymph node involvement.  Survival for persons with distant metastasis (spread to organs such as the liver and lungs) is dismal, with less than 10% surviving beyond five years. [2, 3]

Colorectal cancers have a long latency period during which precancerous polyps and early stage cancers can be detected.[4] Detection and treatment of early stage disease is shown to significantly reduce CRC morbidity and mortality. Several randomized studies have demonstrated that screening for CRC is not only effective, but also cost effective in reducing CRC mortality. [5-7] Screening rates for CRC, however, remain significantly lower than for other cancers such as prostate, breast and cervical cancer.  In 2001, only half of age appropriate adults were screened within the recommended guidelines.

The United States Preventive Services Task Force (USPSTF) and the American Cancer Society recommends screening for colorectal cancer with colonoscopy or flexible sigmoidoscopy with fecal occult blood testing beginning at age 50.  [8]

African Americans have a proportionally higher incidence of colorectal cancer than Whites (57 versus 47 per 100,000), are more likely to be diagnosed with advanced disease and have a higher mortality (24.9 versus 17.4 per 100,000).[9].   African American males have the highest overall death rate from colon cancer compared to all ethnic groups. At 31 deaths per 100,000 persons, African American males residing in New York City are 30% more likely than white men, 41% more likely than Hispanic men and nearly 50% more likely than Asian men to die from colon cancer.[10]  

Consistent with national data, African American males living in NYC have lower rates of screening than their white counterparts (53% vs. 44%).  This lack of screening, contributes to colon cancer disparities seen in black males.[10]  

We undertook a retrospective analysis of colorectal cancers diagnosed in Africans Americans at The Brooklyn Hospital Center, a community hospital in New York City, in order to discern patterns of presentation and make inferences regarding current screening practices. 

 

Methods:

 Data was obtained from The Brooklyn Hospital Center tumor registry.  A total of 327 cases of adenocarcinoma of the colon were diagnosed at our institution between 2002 and 2006.  Anatomical site of the primary tumor as well as age, sex and race of the patient was analyzed.   At the time of admission to the hospital, racial data is obtained by means of an open-ended questionnaire. 

 Results:

 The analysis of 327 cases of Colon showed 78% were African Americans. Other races comprised of only 22%. Final analysis was performed on the 256 cases occurring in African Americans. Results are shown in table 1 and 2.

 Table 1

Anatomic site of primary colon lesion

Gender

 

Male

Female

Total

Number/percent

 

97 (38)

159 (62)

256

Site of primary

Right colon

39 (40)

75 (47.16)

114

Left colon

57 (58.76)

83 (52.2)

140

Overlapping

1 (1.03)

1 (0.6)

2

 

                          Colon cancer in African Americans by gender and age

 

Male

Female

Total

<49

6  (6)

15 (9)

21 (8)

50-59

18 (19)

31 (20)

49 (19)

60-69

32 (33)

35 (22)

67 (26)

>70

41 (42)

78 (49)

119 (47)

 

 

Conclusions: 

 Our analysis reveals that fewer African American men than women were diagnosed with colon cancer at our institution.  In addition, African Americans and African American men in particular had less right-sided colon cancers than cancers of the left colon.  This is sharp contrast to published literature that describes the incidence of right-sided colon cancers as 54% in the general population. [11].  Reported rates for right-sided cancers in Blacks are even higher [12]  

We postulate that these differences signify inadequate and ineffective screening for colon cancer in African American males rather than a true biologic trend.   In 2005 physician experts from the American College of Gastroenterology issued new recommendations to healthcare providers to begin colorectal cancer screening in African Americans at age 45 rather than 50 years.  The Committee recommended colonoscopy as a “first line” screening procedure for colorectal cancer for African Americans rather than flexible sigmoidoscopy. [13] Community based physicians may be more familiar with the American Cancer Society and the USPSTF guidelines that begin screening at age 50 and allow for flexible sigmoidoscopy.  Using these guidelines, younger patients with right-sided lesions will be “missed”.  Our difference in rates and presentation among African American males is undoubtedly a reflection of “missed” cases.

Our data provides support for aggressive screening programs geared towards Africans Americans utilizing colonoscopy rather than sigmoidoscopy beginning at age 45. Primary care physicians should familiarize themselves with the American College of Gastroenterology’s recommendations and African American patients should be educated regarding the age of onset and the risks and benefits of the currently available colon cancer screening modalities.

References

  1. Cancer Facts & Figures – 2008, American Cancer Society (ACS), Atlanta, Georgia, 2008.

  2. 2.      SH Landis, T Murray, S Bolden, PA Wingo. Cancer Statistics, 1999. CA Cancer J Clin 49 (1): 8

  3. Vernon, S., Participation in colorectal cancer screening; a review. Journal Of The National Cancer Institute, Vol 89, 1406-1422

  4. U.S. Preventive Services Task Force. Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 2008 Nov 4;149(9):627-37. PMID: 18838716

  5. Jack S. Mandel, Timothy R. Church, Fred Ederer, John H. Bond. Colorectal Cancer Mortality: Effectiveness of Biennial Screening for Fecal Occult Blood. Journal of the National Cancer Institute, 1999 Mar 3;91(5):434-7. PMID: 10070942

  6. Pignone M, Saha S, Hoerger T, Mandelblatt J. Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2002 Jul 16;137(2):I38. PMID: 12118964

  7. David F. Ransohoff, MD, and Christopher A. Lang, MD . Screening for Colorectal Cancer with the Fecal Occult Blood Test. Annals of internal medicine 1997 May 15;126(10):811-22. PMID: 9148658

  8. SEER Cancer Statistics Review, 1975-2004, National Cancer Institute, Bethesda, MD, http://seer.cancer.gov/csr/1975_2005/, based on November 2007 SEER data submission, posted to the SEER web site, 2008.

  9. U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008 Nov 4;149(9):627-37. PMID: 18838716

  10. Feldman, G., C. McCord, and T. Frieden, Preventing colorectal cancer, in City Health Information. 2003: New York. p. 1-4

  11.  Jessup JM, McGinnis LS, Steele GD Jr, Menck HR, Winchester DP. The National Cancer Data Base. Report on colon cancer. Cancer. 1996 Aug 15;78(4):918-26. PMID: 8756390

  12.  Irby K, Anderson WF, Henson DE, Devesa SS.Emerging and widening colorectal carcinoma disparities between Blacks and Whites in the United States (1975-2002). Cancer Epidemiol Biomarkers Prev. 2006 Apr;15(4):792-7. PMID: 16614125

  13. Taylor, V., et al., Colorectal cancer screening among African Americans: the importance of physician recommendation. Journal of the National Medical Association, 2003. 95(9): p. 806-812. PMID: 14527047