Addressing Racial Disparities in Colorectal Cancer

Overall, rates of CRC have decreased in recent years. This is due to higher rates of screening and early detection or prevention.

Still, rates among African Americans are higher compared with other groups. According to the American Cancer Society (ACS), African Americans are 20% more likely to receive a diagnosis of colorectal cancer. They’re also about 40% more likely to die from colorectal cancer.

Research from 2021 suggests that Native Americans are also at an increased risk.

There are many reasons for this disparity. It’s likely a combination of genetics, healthcare access, and systemic racism.

Screening is important for diagnosing CRC at an earlier stage. A colonoscopy can even prevent cancer.

Polyps are growths in the lining of the colon or rectum. In some cases, they become cancerous. During a colonoscopy, a doctor can find and remove polyps.

Black people in the United States are 8% less likely to have screening colonoscopies than other groups. This means a doctor may not detect CRC until a later stage. Advanced CRC has fewer treatment options.

People who don’t have health insurance are more likely to get a diagnosis at a later stage. While the Affordable Care Act (ACA) expanded health insurance coverage, many remain uninsured. In 2019, 12% of Black people and 20% of Hispanic people still didn’t have health insurance.

Black people are also more likely to receive a diagnosis at a younger age. In the overall population, about 5% of CRC diagnoses occur before the age of 50. But among Black Americans under the age of 50, that number more than doubles to 11%.

Survival for Blacks is also much worse if they have early-onset CRC. According to 2016 research, non-Hispanic Blacks were 35% more likely to die from early-onset CRC than non-Hispanic whites with the same disease. Disparities were greatest for Black people with stage 2 colon cancer or stage 3 rectal cancer.

Black people in the United States die more often from colorectal cancer compared with other groups. Higher rates of poverty and lower rates of health insurance are part of this story. A lack of inclusion in clinical trials and a lower quality of cancer care also contribute.

Traditionally, research doesn’t include People of Color in numbers that reflect the true population. This leads to a lack of understanding of how different treatments may work in different populations. It also means People of Color may not be able to access life-saving treatments that may be part of a clinical trial.

Research shows that Black people are less likely to receive the same level of care as white people. They are more likely to wait longer before starting treatment for CRC. They are less likely to have radiation, chemotherapy, and surgery. Delays in treatment mean worse outcomes for people with colorectal cancer.

Expand Medicare coverage

Expanding insurance coverage has helped increase access for many people from lower income households. The ACA and Medicare expansion in several states is helping.

At the time Congress passed the ACA in 2010, 20% of Black people in the United States didn’t have health insurance. By 2019, 12% of Black people were still without health insurance. While this number is better, a lot of people are still without coverage.

Among white people in the United States, the number of uninsured was 9% in 2019.

Increase access to clinical trials

The medications and treatments doctors use today started in clinical trials. Trials may be an opportunity to access life-saving care before it’s widely available.

People of Color are underrepresented in clinical trials. Doctors are less likely to mention clinical trials to Black patients. There may also be exclusion criteria that block many People of Color from being part of trials.

Cost is another barrier for many. Even with health insurance, transportation costs, child care, and time away from work all add up. Being in a clinical trial can add even more costs. Those costs are a huge burden to anyone, but especially for someone already living in poverty.

Data from 2021 shows that 21.7% of Black people in the United States live below the poverty line. Compare that with 9.5% of white people in the United States.

There are moves toward better representation in clinical trials. Having multiple trial sites that include community clinics helps to increase diversity. It’s also important that patients know about clinical trial opportunities. Every patient should know their options.

To support more people joining clinical trials, some programs help cover the extra costs of involvement.

Greater understanding of medical mistrust

Medical mistrust is a major barrier to cancer screening and joining clinical trials. It also decreases healthcare access for many Black people.

Research has shown that about 25% of Black people in the United States feel a high level of medical mistrust. This makes sense with the history of lower quality care at segregated hospitals. There’s also a long, dark history of abuse of People of Color by the medical community.

Even research in the past decade shows that there are harmful beliefs about Black people regarding pain tolerance. These beliefs result in healthcare professionals denying many Black people appropriate pain medication and treatments.

Healthcare professionals need to take steps to ensure that Black people feel heard and understood. Building rapport and trust are essential to improving care.

Improve follow-up care

Historically marginalized people and those with lower incomes have more delays in starting treatment. A 2020 review of studies shows that patient navigators can help people in these groups overcome some of the barriers to CRC screening and care. Having a system to identify patients who are at greater risk can help save lives.

One intervention showed the benefits of a structured screening plan for colorectal cancer. The goal was to ensure that all people received the same level of follow-up and care. In this study, death from colorectal cancer decreased in all groups.

The greatest improvement was among Black people due to the initial disparity. Researchers mailed annual home screening kits to all patients to test for blood in their stool. They also offered colonoscopies as needed.

At the start of the study in 2000, 42% of the 88,734 Black participants were up-to-date with screening. From 2015 to 2019, 79% to 80% were up-to-date.

Know your family history

Experts estimate that about 35% of the risk for CRC comes from genetics. If you have a family history, a doctor may recommend you start screening earlier. It depends on the number of family members with CRC and their age at diagnosis.

Not everyone has access to their family history. If this is the case for you, it’s smart to let a doctor know this too. Based on any other risk factors, you and your healthcare team can make a screening plan that makes sense for you.

Learn more about genetic testing for colon cancer.

Receive screening

Screening is essential for early diagnosis or prevention of colorectal cancer. There are several different screening tests for CRC. There are pros and cons to each. You can discuss the options with your doctor.

At-home screening options include:

• every year
• fecal occult blood tests (FOBT) every year
• stool DNA test (Cologuard) every 3 years
• blood-based biomarker test (Epi proColon) every 3 years

A doctor can also perform the following screening tests:

• colonoscopy every 10 years
• CT colonography every 5 years
• flexible sigmoidoscopy every 5 years

Watch for signs and symptoms

People with colorectal cancer don’t always have signs or symptoms. This is why screening is so important. If you notice any changes in your bowel habits, it’s smart to get them checked out.

Signs and symptoms of colorectal cancer include:

• changes in bowel movements, such as diarrhea, constipation, or narrow stool shape
• bright red blood with a bowel movement
• darker-colored or black stool, which may indicate dried blood
• fatigue
• unexplained weight loss
• low red blood cell counts (anemia) due to blood loss

CRC is the third most common type of cancer and the second highest cause of cancer death in the United States. Black Americans have higher rates of CRC and are more likely to die from it. There are many reasons for this.

Higher poverty levels and lower levels of health insurance are part of the story. Black Americans are also more likely to receive a diagnosis under the age of 50. They have higher rates of right-sided colon cancer, which has worse outcomes.

On a systemic level, increasing health insurance, having better follow-up plans, and finding ways to build trust among People of Color may help. It’s also important for people to be aware of any family history and have regular screening done.

Colorectal cancer may not have any signs or symptoms at an early stage, so regular screening is the best way to catch it early. Early diagnosis improves your chances of a better outcome.