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How a team of doctors is eyeing equity when it comes to colon cancer
“There’s lots of data that regular screening is associated with a mortality benefit, a mortality benefit of 20 to 30 percent."
Colorectal cancer is the second most common cause of cancer-related deaths in all Americans, and of all racial and ethnic groups, Black Americans have the highest incidence and death rates.
But a new team, funded by Stand Up To Cancer, Exact Sciences, and Providence health system, is hoping to increase screening levels among underserved communities, including those in Greater Boston.
The group — which has three different zones, including the Greater Boston region, plus the Great Plains Tribal Communities in South Dakota, and Los Angeles — also hopes to help build the careers of new doctors of color.
Screening rates decline during the pandemic
Dr. Jennifer Haas of Massachusetts General Hospital is one of the leaders of the Stand Up To Cancer Colorectal Cancer Health Equity Dream Team. Screening is the best way to prevent colorectal cancer, she said.
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“There’s lots of data that regular screening is associated with a mortality benefit, a mortality benefit of 20 to 30 percent,” she told Boston.com in a recent phone interview.
But due to the COVID-19 pandemic, screening rates took a nosedive during its early days.
“The screening rates dropped tremendously,” she said. “They pretty much went to, we weren’t doing any screening.”
The rates prior to the pandemic were about 65 percent, but COVID-19 dropped them to about a quarter of what they were, according to Haas. Then, as society began to live with the pandemic, screening went back up again over the six to eight months following the pandemic onset in March and April of 2020.
Through the team, the goal is to raise screening rates to 80 percent within the identified zones, according to a press release.
Part of raising the screening rates hinges on working with community health centers. About half to perhaps three-quarters of the difference between why someone with a lower socioeconomic status is more likely to be diagnosed with colon cancer has to do with accessibility.
“I think the concern is that those folks aren’t getting screened with frequency,” Haas said. “There may also be some risk factors for colon cancer in terms of diet, or behavioral risk factors. But primarily it’s because of inadequate screening.”
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“Some risk factors” could be related to diet and alcohol, she said. But, “I really think it’s a failure of care.”
What screening actually involves
When someone thinks of colorectal cancer screening, they may automatically think of a colonoscopy procedure, which uses a tube and a light to inspect the colon. If any polyps are found, a doctor can remove a piece for biopsy. But home-based tests are now a big part of it.
There are two approved home-screening tests available. One is an amino test that looks for blood in the stool, according to Haas. The other is a test that looks for DNA associated with colon cancer.
“Both are very relatively simple tests to do at home,” Haas said. “We send a pack in the mail and then you’re notified of the results.”
These have become especially important now with a backlog of colonoscopies — 10,000 procedures were canceled during the height of the pandemic, and all need to be rebooked, Haas said.
One way to catch up is with the home-based test. A positive test means the need for a colonoscopy. However, using these could mean a lack of follow-up, even with a positive result.
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“I think at this point one of the bigger issues is that it’s very hard to get a follow-up colonoscopy booked,” she said.
What are the screening barriers?
Through the new team and associated grants, Haas said working with community health centers is key, plus working in communities to promote screening.
“I think we very much look forward to working with those community organizations,” she said. “We’re in the process of engaging four community health centers and working with clinicians and stakeholders — they all have community advisory boards that include patient representatives — to understand what the barriers are in their specific clinics both generically, but also now with the pandemic ongoing, to try to get people to participate with both screening and diagnostic evaluation.”
It’s early to say what the barriers are, but according to Haas sometimes screening happens when it’s opportunistic. Waiting for a patient to go in and then seeing they are overdue for screening means that a doctor could be “missing the opportunity to intervene.”
Part of it is being proactive, and that’s something that health care systems have done, but not so much “with an eye to equity,” Haas said. The overall screening rate may be high, but perhaps they haven’t broken it down to look at screening rates of white patients versus Black patients.
There needs to be a dashboard dedicated to equity, according to Haas.
A pipeline for doctors of color
Part of the Stand Up To Cancer grant has to do with “promoting early-career investigators,” Haas said, noting that she’s been working with three new doctors of color. “One of the keys” is to help them to find a specific area of expertise, and help them promote their careers.
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But it’s not only recruiting, she said; it’s maintaining the doctors of color already on board.
“Boston has a complicated history with race,” she said. “I think historically it’s been very difficult to recruit Black and Latinx physicians. I think in Boston that’s changing. I think the institutions are really making a concerted effort to recruit. I think it’s not just recruiting people, but also maintaining what you have.”
She said health care systems are already making investments in this area.
“I think it’s hard but I think hopefully we’re sort of seeing a little bit of a turning point in terms of institutional investment and career development,” Haas said.
There’s evidence that suggests a variety of better outcomes when a patient can see a doctor of their own race or ethnicity. Some of those include understanding the chances of getting cancer, willingness to undergo a treatment, and even just how the patient feels about their time with the doctor, according to an article in The Conversation by Ryan Huerto, a lecturer at University of Michigan and a physician, and Edwin Lindo, a lecturer at University of Washington School of Medicine.
“In the current workforce, diversity among physicians is limited,” they said in the article. “That can lead to mistrust in doctor-patient relationships, even during routine checkups. Black patients, for instance, may feel more wary with a white doctor than a black doctor, and white doctors may feel less comfortable caring for minoritized patients.”
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A study at Stanford University showed the positives of Black men seeing a Black doctor versus a white doctor.
“The men seen by black physicians were more likely to engage with them, and even consent to preventive services like cardiovascular screenings and immunizations,” the article said.
The American Cancer Association recommends talking to your doctor about a colorectal screening if you are 45 or over. While colorectal cancer often doesn’t present symptoms during its early stages, some to look out for are changes in bowel habits, bleeding, cramping, and weakness and fatigue, according to the ACS. For information, visit cancer.org.
