Reducing colorectal cancer risk among African Americans.

摘要: Colorectal cancer (CRC) burden is not equal among populations in the United States. African Americans have highest CRC incidence and mortality of all US populations, rates are decreasing to levels non-Hispanic Whites.1 In addition increased risk, adenoma risk also higher Americans, both adenomas cancers occur more frequently proximal colon at younger ages Americans.2 Reasons for population differences multifactorial include tumor biology behavior, genetic access health care, screening rates.3,4 As demonstrated by Delaware program, strategies maximize hold significant promise correcting disparities.5 Current Multisociety Task Force guidelines recommend average beginning age 50 years, individuals (such as those with family history, inherited syndromes or inflammatory bowel disease) recommended begin earlier.6 Owing earlier neoplasia some professional organizations starting 45.3 Others raise concerns about impact complicating existing standardized unclear benefit despite an proportion under years. They that efforts should focus instead on improving 50. Given this controversy, it timely examine how our profession can take lead reducing disparities Americans. Several be considered when prioritizing (Table 1). Table 1 Strategies Decrease Disparities Cancer Among (AAs) African less knowledgeable compared Caucasians,7 likely transmit a history cancer.4 Both lack knowledge benefits fatalistic views associated reduced likelihood Americans.8 Interventions designed educate patients improve attitudes,9,10 contain culturally sensitive materials been shown boost Americans.9 These other studies suggest surmountable barrier, but challenges remain. For example, ≤40% aged 65 years older areas estimated read below 5th-grade level,9 limiting use materials. addition, patient education approaches may work groups, potentially necessitating individualized interventions inclusion personnel engage community-based outreach. The provider endorsement cannot under-estimated. Lack recommendation important barrier Americans.11 However, evaluate lacking. Continuing medical seminars increase knowledge, whether translates improved clear.12 Just there no education, education. Moreover, providers cite insufficient time recommending patients,13 causing additional delay population. Strategies focused physician screening, research needed demonstrate this. Patient navigation proven strategy increasing improves show preparation.3,14 A randomized trial phone printed material versus alone found 53% endoscopic group literate subjects showing stronger effect from navigation.14 Financial modeling based program New York City cost effective,15 whereas noted greater costs tailored navigation.16 Implementation into “real world” complex requires flexibility cooperation stakeholders.17 Thus, although logistics major barriers widespread adoption. Efforts overcoming these through research, advocacy screening. A controversial lower initial Arguments supporting neoplasia, stage ages, location tumors Americans.3 Lieberman et al2 showed rate high polyps (>9 mm) was 17%–38% American men 50-69 25%– 50% women 50-64 Caucasian groups. Although large statistically different <50, sample size small, power detect true subgroup. simulation study argued favor well shortening intervals 1 year given life-years gained.18 prevalence argues colonoscopy preferred modality. If we consider race heritable factor,4 changing recommendations akin already stratify has potential prevent who currently detected early enough. Population-specific raises awareness could overall. Arguments against definitive evidence before years.2,19 To address this, comparative effectiveness enrolling performed. Another argument current population-based would further confuse physicians. Further modifications negatively adherence; however, support notion. changes breast prostate led public confusion,20,21 largely intensified more. prefer non–endoscopy-based examinations,22 perhaps focusing structural examinations simplifying message encourage any kind acceptable most appropriate comprehensive strategy. Increasing 5%–10% effective than age.19 gap Caucasians closing, certainly done. Finally, insurance coverage endoscopy resources real concern will only changed if consensus bodies authoring guidelines. CRC unacceptably high, representing disparity, reduce disparity. Patient implementation navigators receive considerable attention. Whether implementing new population-specific augment remains unclear; now establish issue establishing expert panel review data formulate updated evidence-based including formal regarding optimal Such help us make progress equity form basis approach care