By Estell Williams, MD and Rachel Issaka, MD, MAS
“When I stand before God at the end of my life, I would hope that I would not have a single bit of ability left and could say, ‘I used everything You gave me’.” – Chadwick Boseman
2020 has been a traumatic year for Black Americans. The COVID-19 pandemic shined a bright light on systemic racism and non-Black Americans are realizing how police violence, redlining, unemployment, environmental injustice, poverty, and more, disproportionately impacts Black communities and contributes to health inequities. Thus, the loss of Chadwick Boseman, the Black Panther, cuts even deeper into an existing wound without signs of rescue or healing on the horizon.
Chadwick died at the age of 43 from colorectal cancer after being diagnosed with advanced stage disease at 39. He was a husband, a son, a descendant of slaves, a graduate of a Historically Black College and University, and a beacon to young Black people. He was a superhero on and off the screen and urged us all to press on unapologetically in pride and purpose.
Colorectal cancer is the second leading cause of cancer deaths in the United States. While the overall incidence and mortality from colorectal cancer has decreased by over 30% since 1985, only 67% of eligible Americans are up-to-date with screening and new cases among those under the age of 50 are rising. Between 2008 and 2017, colorectal cancer cases increased by 2% each year for those under 50. While the absolute numbers are still much lower compared to those over 50, the trend is concerning. Patients under age 55 are also 58% more likely to be diagnosed with late-stage colorectal cancer, which carries a 5-year survival of 14%.
The burden of colorectal cancer is not evenly distributed. Black people are 20% more likely to be diagnosed with colorectal cancer, 40% more likely to die once diagnosed, and more likely to present with advanced stage disease compared to non-Hispanic Whites. When diagnosed, Black Americans are less likely to receive newer chemotherapeutic agents or receive care in a high-volume facility, where outcomes are best. In every age category, colorectal cancer mortality is highest among Black people, particularly Black men. For those who are under 50, later stage disease and associated mortality is postulated to be due to delays in evaluation of signs and symptoms concerning for colorectal cancer. These include changes in bowel habits or stool caliber, rectal bleeding, abdominal pain, unintentional weight loss or unexplained fatigue. Because these symptoms are not specific to colorectal cancer, patients may delay seeking evaluation and providers without a high-index of suspicion may not immediately refer these patients for endoscopic evaluation.
While the United States Preventive Services Task Force (USPSTF) and most gastroenterology societies recommend screening begin for average-risk individuals at age 50, since 2008, the American College of Gastroenterology has recommended that Black people begin screening at 45. In 2018, based on the trends of rising colorectal cancer incidence in those under 50, the American Cancer Society provided a conditional recommendation that all average-risk screenings begin at age 45. For those with an increased risk of colorectal cancer, either due to family history of colorectal cancer, a known inherited genetic syndrome, or inflammatory bowel diseases (Ulcerative Colitis and Crohn’s disease), screening should begin earlier. Therefore, it is critical to have regular conversations about family medical histories, colorectal cancer risk, and the appropriate age to begin screening with patients. Anyone, regardless of age, with signs and symptoms of colorectal cancer should be referred for endoscopic evaluation.
The 2010 Affordable Care Act (ACA), mandated that insurers (including Medicaid in expansion states), cover preventative services including colorectal cancer screening. In an analysis comparing pre- and post-ACA colorectal cancer screening, although the ACA led to increased screening for all, disparities by race and ethnicity persisted with the screening gap between Black and non-Hispanic Whites actually increasing over time. The National Institutes of Health considers health care disparities one of the most important issues facing the U.S. health system. Therefore, physicians and surgeons must seize every opportunity to address racial health disparities, including addressing the underlying factors that ultimately lead to poor health outcomes. Pertaining specifically to colorectal cancer, here is how you can engage:
- Speak with your patients about their family medical history. Black Americans with a family history of colorectal cancer have the lowest likelihood of participation in screening.
- Stress to your patients the importance of family medical history knowledge. Black Americans are less likely than non-Hispanic Whites to know their complete family history of cancer and are also more likely to have inaccurate knowledge of their family history of cancer. Screened family members are less likely to tell their relatives about the finding of colon polyps. This information gap has the potential to incorrectly risk-stratify patients and cause delays in screening initiation and challenges with insurance coverage of colonoscopies.
- Educate your patients on the various options for colorectal cancer screening tests. Colorectal cancer screening rates for Black people lag behind non-Hispanic Whites. Mailed stool-based tests, tailored patient education combined with patient navigation services, and enhanced physician-patient communication, can modestly improve adherence to colorectal cancer screening.
- Set your patients up for success. Develop a low threshold for gastroenterology referral for evaluation of concerning signs or symptoms. Surgeons should consider if elective operations (unrelated to CRC) can be delayed until patients have completed an initial colorectal cancer screening test. This change in practice can help reinforce the importance of prevention and support primary care and gastroenterology colleagues. General and subspecialty surgeons have unique patient relationships and educating patients on the importance of screening and symptom evaluation, will empower them to take ownership of their health and well-being.
While we cannot bring our brother Chadwick back and we do not know the circumstances leading up to his diagnosis, his loss is a rallying cry to amplify our voices to achieve health equity for Black Americans, including improving colorectal cancer outcomes.
Estell J. Williams, MD, is Assistant Professor of Surgery in the Division of Emergency General Surgery at University of Washington School of Medicine. Dr. Williams grew up in Oakland, CA and studied biology and chemistry double major at Xavier University of Louisiana before being displaced by Hurricane Katrina and completing her undergraduate degree in biology from the University of San Francisco. She earned her Medical Doctorate from the University of Washington, where she also trained in general surgery and was recruited to join the faculty after graduation. She also is the Executive Director of the Doctor For A Day (DFAD) Outreach Program through the University of Washington, School of Medicine. Outside of work, Dr. Williams enjoys spending time with her husband, a critical race theorist who also works at the University of Washington, running a social justice library with her husband named after their 3 year old daughter and raising her young daughter and 15 year-old niece. You can find Dr. Williams on Twitter/Instagram at @drwooda.
Dr. Rachel Issaka is a Gastroenterologist and Assistant Professor at the Fred Hutchinson Cancer Research Center and the University of Washington with expertise in colorectal cancer prevention, quality improvement, and health equity. Dr. Issaka has contributed to national gastroenterology guidelines as a member of the National Comprehensive Cancer Network (NCCN) colorectal cancer guideline committee, and guidance documents on colorectal cancer screening for the National Colorectal Cancer Roundtable (NCCRT) and the Centers for Disease Control (CDC) workgroup on mailed fecal immunochemical test (FIT) outreach. Dr. Issaka’s research focuses on decreasing colorectal cancer mortality through increased screening in medically underserved populations. Her work has been funded by the National Institutes of Health and the Centers for Medicare and Medicaid Services. Dr. Issaka completed her gastroenterology fellowship at the University of California, San Francisco where she also earned a Masters in Advanced Studies in Clinical Research. She completed her internal medicine residency at Northwestern University Feinberg School of Medicine, where she served as chief resident and obtained her medical degree from the University of Michigan Medical School. You can find Dr. Issaka on Twitter/Instagram at @IssakaMD.
Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.