Colorectal Cancer Disparities in US: 'We Should Be Embarrassed'
Fonte: http://www.medscape.com/viewarticle/838916?src=wnl_edit_tpal#vp_3
It has long been known that there are disparities in mortality rates from colorectal cancer (CRC) between educated white and uneducated black populations in the United States.
A recent study concluded that lack of education, regardless of race or ethnicity, is the most important factor in such disparities (J Clin Oncol. Published online November 10, 2014).
Increasing public health education and access to care are both key to closing the survival gap, experts say.
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Dr Blaise Polite
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In the study, the level of education was used as a marker for socioeconomic status. "We can quibble about the limitations" of it being an adequate standalone surrogate, writes Blaise Polite, MD, MPP, from the University of Chicago Medical Center, in a related editorial published online January 20 in the Journal of Clinical Oncology.
Nevertheless, he adds, "the major finding from this study...remains unaltered: If you are black or have low educational attainment, where you live in the United States determines how likely you are to die as a result of colorectal cancer. That is an experiment that has to end in the 21st-century United States."
"Between 2008 and 2010, more than 23,000 deaths from colon cancer, 50% of the total, could have been prevented if all states had colon cancer equal to the five states with the lowest rates for the most educated whites. An equally important point is the variation among the states; 69% of deaths could have been prevented in Mississippi, compared with only 29% in Utah," he notes.
"There is absolutely no excuse in 2015 for these kinds of disparities to still exist," Dr Polite told Medscape Medical News. "We should be embarrassed."
Analysis of Premature CRC Deaths
The study, led by Ahmedin Jemal, PhD, from the American Cancer Society in Atlanta, looked at the rate of death from CRC in people younger than 65 years (i.e., premature death) in each of the 50 states from 2008 to 2010.
The researchers classified CRC patients 25 to 64 years of age by level of education (12 years or fewer, 13 to 15 years, and 16 years or more), race/ethnicity, and state.
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Dr Ahmedin Jemal
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The study, led by Ahmedin Jemal, PhD, from the American Cancer Society in Atlanta, looked at the rate of death from CRC in people younger than 65 years (i.e., premature death) in each of the 50 states from 2008 to 2010.
The researchers classified CRC patients 25 to 64 years of age by level of education (12 years or fewer, 13 to 15 years, and 16 years or more), race/ethnicity, and state.
They found there were significantly more premature CRC deaths in states with the lowest education levels than in those with higher levels. In fact, rates of premature death decreased with increased years of education, regardless of race or ethnicity.
In the white population, Delaware had the fewest premature CRC deaths, but even in that state, the rate was 15% higher in the least-educated than in the most-educated people (rate ratio [RR], 1.15; 95% confidence interval [CI], 0.66 - 2.01). New Mexico had the most premature CRC deaths; the rate was 3-fold higher in the least-educated than in the most educated people (RR, 3.18; 95% CI, 2.01 - 5.05).
In the black population, rate ratios ranged from 0.84 (95% CI, 0.54 - 1.30) in Mississippi to 2.41 (95% CI, 1.62 - 3.59) in Virginia. New York had the lowest death rate (12.9%) among those with the lowest level of education.
"Level of education was a factor in determining premature deaths from colorectal cancer in all states," Dr Jemal told Medscape Medical News. "Education was a major factor everywhere. But it is important to make clear that we are using level of education attainment as a marker for socioeconomic status. Level of education is not a causal factor, it is an indicator of poverty or knowledge," he cautioned.
Half the 7690 premature CRC deaths that occurred annually from 2008 to 2010 would have been avoided if the rate everywhere was equivalent to the lowest death rate of the most-educated white population, the researchers report.
Dr Jemal said he believes education level is a factor in CRC screening rates.
"Screening is recommended for people 50 to 75 years. In those with 12 years or less of education, only 40% get screened, compared with 70% of those with a college-level education," he explained. Even worse, "in the uninsured population, it is only 19%. That is ridiculously low, and highlights the importance of access to care."
Access to care also affects the ability to be treated if screening indicates the presence of cancer, he added.
In the United States, "if you do not have health insurance, you will not be able to get curative treatment because surgery is very expensive, and so is adjuvant chemotherapy, which works very well for colorectal cancer if one can afford it," Dr Jemal said.
People with less education tend to be poor and have more high-risk behaviors than their more educated counterparts, which contributes to the excess death, he explained.
"For instance, smoking is a risk factor for colorectal cancer. The smoking prevalence in people with less than 12 years of education is three times as high as in people with more years of education. Obesity is also higher in those with lower educational attainment, so the higher rates of premature death that we saw in this study is due to a combination of reduced access to care and these behavioral risk factors," Dr Jemal said.
The American Cancer Society is hoping to bring awareness of the problem to legislators and other stakeholders through its newly launched Action Network (ACSAN).
"The ACSAN has a relationship with the US Congress, and we hope Congress will work with us to increase public awareness and education about screening. We also want to reach the vulnerable population with poor education. Often they are misguided and do not even work in their own interest. I live in the southern United States and I see and hear this. There are poor people who are against the Affordable Care Act, saying they do not want the government to be involved in their business. We need to educate them," he said.
Make Public Health and Access to Care Priorities
In his editorial, Dr Polite commends Dr Jemal's team "on this innovative use of available public health data."
A large part of the CRC disparities are likely related to general public health issues, Dr Polite told Medscape Medical News.
"Getting people screened, and once they are screened making sure that they are diagnosed and treated and followed in an appropriate manner, is key to reducing such disparities. If we do those things, we can eliminate a large portion of them. This study shows that we can pinpoint states that have done a good job with their public health programs and states that have not done much of anything," he said.
Where There's a Will, There's a Way
For example, Delaware, the state with the lowest rate of premature CRC death, has long made CRC screening, diagnosis, treatment, and follow-up a priority.
"Delaware had champions, such as John Carney, who is now Delaware's representative in Congress. Reducing disparities and getting programs that would screen, treat, and follow everyone affected with colorectal cancer was a priority in Delaware," Dr Polite said.
A similar thing happened in New York.
There, "the public health community, physicians, and everybody got together and made it a priority to eliminate colon cancer disparities. They made that very clear. This is our goal," he explained.
"We see from both New York and Delaware that when you make it a goal, you can achieve it. This is not rocket science," Dr Polite added.
Dr Jemal and Dr Polite have disclosed no relevant financial relationships.
J Clin Oncol. Published online January 20, 2015. Editorial
