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Disparities in Surveillance Colonoscopy Participation: Determining Gender- and Race-Specific Targets for Future Quality Improvement Interventions
Abstracts
331 The Effect of Acculturation On Colorectal Polyp Prevalence Among Hispanics Neal Joseph, Nora Muakkassa, Sergio Quijano, Martin J. Wolff, Fritz Francois
329 Disparities in Surveillance Colonoscopy Participation: Determining Gender- and Race-Specific Targets for Future Quality Improvement Interventions D. Eli Penn, Joseph Romagnuolo Background: In a recent study of patients undergoing screening colonoscopy, we found no significant differences in polyp prevalence or incidence between African Americans (AA) and Caucasians to help explain the higher mortality of colorectal cancer in AAs. There were, however, significant race- and gender-related differences in rates of surveillance colonoscopy participation, an important quality metric of a colon cancer screening program. The aim of the current study was to determine the race- and gender-specific barriers, to surveillance colonoscopy, in Charleston, SC after a polypectomy for adenoma(s). Methods: We identified 170 patients from our adenoma prevalence study who had an adenoma removed but did not return for surveillance colonoscopy within the expected timeframe. For each patient, the pathology was reviewed to confirm the need for surveillance. Patients were contacted by telephone and asked to rate their agreement (5-point Likert scale) with 14 statements, encompassing 4 dimensions of possible barriers: 1) financial (including lack or loss of insurance), 2) communication failures (including knowing how to set up the procedure), 3) compliance (including being too busy, or aversion to the procedure), and 4) understanding (of procedure’s importance). Results: 56 patients were able to be contacted and agreed to participate. Of those, 11 (20%) were AA and 26 (46%) were male. AAs were more likely than whites to cite "financial reasons" or "lack of insurance" for failure to return for surveillance (9% vs 2%). AAs were twice as likely to state they were unaware that they were supposed to come back (36% vs 16%), or claim that they had not been contacted (36% vs 16%) or re-referred (54% vs 23%). Women were five times more likely than men to "never want to have another colonoscopy’’ (20% vs 4%). AAs and women were more likely to agree that screening colonoscopy’s goal is ‘‘to remove polyps before they become cancer’’ and to agree that ‘‘colonoscopy after polyps are removed is important.’’ Conclusions: AAs who failed to return for surveillance colonoscopy in our study had a greater understanding of the purpose for surveillance than their white counterparts, but may have been more likely to expect to be contacted before returning; they were five times more likely to cite financial reasons for not returning. Women had a better understanding of the importance of surveillance colonoscopy than men, but 1 in 5 had an aversion to repeat procedures. These findings will help guide interventions aimed at improving adherence with surveillance colonoscopy after adenoma removal. Supported by a grant from The Center for Health Disparities Research
330 Prevalence of Colon Polyps O9 mm Detected By Colonoscopy Screening in Asymptomatic Hispanic and Asian/Pacific Islander Patients: Results from the National Endoscopic Database Brent Lee, David A. Lieberman, Jennifer L. Holub Compared to whites, Hispanics and Asian/Pacific Islanders have lower incidence and mortality from colorectal cancer (CRC). The purpose of this study was to determine if asymptomatic Hispanics and Asian/Pacific Islanders undergoing colonoscopy screening also have lower age-adjusted rates of polyps O9 mm. Such data could inform future screening guidelines. Aims: To measure and analyze the prevalence and location of polyps sized O 9 mm in diameter in asymptomatic white, Asian/Pacific Islander and Hispanic patients who receive colonoscopy screening. Methods: Colonoscopy data were prospectively collected from the Clinical Outcomes Research Initiative (CORI) database, which represents a consortium of 67 adult gastrointestinal practice sites in the United States. Asymptomatic white (n Z 146,798), Hispanic (n Z 7,654), and Asian/Pacific Islander (n Z 1,567) patients who received screening colonoscopy from 2004 - 2007 were identified. Main outcome measures included prevalence and location of polyps O9mm, adjusted for age, gender, and family history of colorectal cancer in a multivariate analysis. Prior work has shown that polyp(s) O9 mm are closely associated with rates of advanced neoplasia. Results: There was no significant difference in prevalence of polyps O9 mm in white and Hispanic patients (6.2% vs 5.8%; pZ0.11; adjusted OR 0.94; 95% CI 0.85-1.03). Asian/Pacific Islander men and women had a lower prevalence of polyps O9 mm compared to white men and women (4.1% vs 6.2%; pZ0.0004; adjusted OR 0.67; 95% CI 0.52-0.86). When analyzed by decade of age, 60-69 year-old Asians had similar rates of large polyps compared to 50-59 year-old whites (see Table). Conclusion: Compared to whites, Hispanic men and women undergoing screening colonoscopy have a similar risk of polyps O9 mm, whereas Asian/Pacific Islanders have a lower risk. These data suggest that screening colonoscopy might be deferred until age 60 years in average-risk Asian/ Pacific Islanders. Further study is needed to confirm this finding. Prevalence of polyp(s) O 9 mm stratified by race and age.
Age(yrs)
Whites
!50 50-59 60-69 O70
383/8724 3678/69633 3149/44225 1954/24216
Asians (4.4%) (5.3%) (7.1%) (8.1%)
)Asian compared to Whites; p!0.01
www.giejournal.org
2/115 25/799 23/452 14/201
Hispanic (1.7%) (3.1%)) (5.1%) (7.0%)
17/506 190/3770 162/2279 74/1099
(3.4%) (5.0%) (7.1%) (6.7%)
Background: Acculturation, the change in behavior and values that occurs when an immigrant group comes into contact with another group, has been linked to important health outcomes such as coronary heart disease, and breast cancer. The association of acculturation with colon cancer risk is unknown. Our aim was to determine the risk of colonic lesions according to acculturation status among Hispanics. Methods: Consecutive patients referred for screening colonoscopy were prospectively enrolled. A detailed history was obtained, and a validated acculturation survey was administered along with a standardized dietary habit assessment to a subset of self-identified Hispanics. The number, size and location of each polyp were noted during endoscopy. The association between acculturation and adenomas of any size, including advanced neoplasms (adenomas R10mm or any adenoma with villous histology, high-grade dysplasia, or cancer) was assessed. Results: A total of 1,337 patients were enrolled of which 807 (58%) were Hispanic and served as the study cohort. The majority of these patients 749 (93%) were immigrants who had been in the US for 28 16 years. Mean age was significantly higher for immigrants compared to non-immigrants (58 9 vs 51 9; p!0.001), however BMI (27.9 5 vs. 28.1 6) and waist circumference (35 4 vs. 33 4) were comparable. The prevalence of colonic adenomas was higher but not significantly different between immigrants and non-immigrants (16% vs. 12%). In the subset of assessed immigrant Hispanics, age did not differ significantly between acculturated individuals and those who were not acculturated (59 8 vs. 59 9). However the prevalence of adenomas was significantly higher among the acculturated compared to the non-acculturated (25% vs. 11%, pZ0.046). Among the dietary factors assessed, acculturated Hispanics were more likely to consume pastries (72% vs. 55%; pZ0.047) and less likely to drink milk (69% vs. 86%; pZ0.036) compared to their non-acculturated counterparts. After controlling for age, gender, BMI, and number of years in the U.S., acculturation remained a significant predictor of colon pathology (ORZ4.5; 95% CI 1.2-18; pZ0.036). Conclusions: In this colon cancer screening population acculturation was a significant independent predictor of colon pathology among Hispanics, and was associated with a certain dietary profile. Further evaluation of acculturation-related risk factors may help address existing health disparities in colon cancer.
332 Time Trends and Racial Disparities in the Stage of Diagnosis of Esophageal Adenocarcinoma (EAC) in the United States Sachin B. Wani, Amit Rastogi, Mandeep Singh, Vikas Singh, John D. Keighley, Ajay Bansal, Prateek Sharma Background: The incidence of EAC continues to increase in US at an alarming rate. Overall 5-year survival rate for EAC is ~15% and is dependent on its stage of diagnosis. Aims: a)Study the trends in the stage of diagnosis of EACb)Assess racial disparities in the stage of diagnosis of EAC. Methods: The Surveillance Epidemiology and End Results (SEER) database of NCI was searched to identify all pts diagnosed with invasive EAC between January 1, 1976 and December 31, 2005. Data from 9 population-based registries were used to calculate incidence rates of EAC. Age-adjusted incidence rates, using the 2000 US standard, and 95% confidence intervals (CI) were calculated by gender and race (whites, blacks, and others) using SAS. These were calculated in six discrete 5-year time periods (1976-1980 through 2001-2005). Tumor stage was defined as SEER Historic Stage (local - confined to the esophagus; regional - invaded adjacent tissues or spread to regional lymph nodes; distant - metastasized or with distant lymph node involvement; unstaged). To assess for an overall change in the stage of diagnosis, c2 test of equal proportions across time was performed. To assess for a change in the individual stage of diagnosis, Cochran-Armitage test for trend were performed. Results: Between 1976 and 2005, 10,596 cases of EAC were diagnosed. Incidence of EAC/100,000 person-yrs increased from 0.51 in 1976-80 (95% CI 0.47-0.57) to 2.54 2001-05 (95% CI 2.45-2.63), an increase of 400%. In 2001-2005 (compared to 1976-1980) significantly higher number of local and regional EACs were diagnosed [33% increase in local tumors,32% increase in regional]; p for trend for both !0.0001 whereas lower number of distant cancers were diagnosed;p for trend Z0.0002. Significantly less tumors were unstaged in 2001-05 compared with 1976-80 (decline of 57%, p for trend !0.001). Incidence of EAC among whites increased 4-fold with significantly more tumors diagnosed at a local and regional stage; (39% increase in local tumors, 32% increase in regional, p for trend for both !0.0001; 6% decrease in distant, p!0.0005). The incidence of EAC among blacks also increased 2-fold but no significant change in the stage of diagnosis was noted. Conclusions: Updated results (up to 2005) of this population-based study suggest that the incidence rates of EAC continue to rise in whites and blacks. Currently, significantly more EAC are diagnosed at the local and regional stage along with a significant decrease in the distant and unstaged cancers in whites; however, a similar trend was not seen among blacks. Determination of factors driving these racial disparities in EAC stage diagnosis need to be explored.
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB105
331 The Effect of Acculturation On Colorectal Polyp Prevalence Among Hispanics Neal Joseph, Nora Muakkassa, Sergio Quijano, Martin J. Wolff, Fritz Francois
329 Disparities in Surveillance Colonoscopy Participation: Determining Gender- and Race-Specific Targets for Future Quality Improvement Interventions D. Eli Penn, Joseph Romagnuolo Background: In a recent study of patients undergoing screening colonoscopy, we found no significant differences in polyp prevalence or incidence between African Americans (AA) and Caucasians to help explain the higher mortality of colorectal cancer in AAs. There were, however, significant race- and gender-related differences in rates of surveillance colonoscopy participation, an important quality metric of a colon cancer screening program. The aim of the current study was to determine the race- and gender-specific barriers, to surveillance colonoscopy, in Charleston, SC after a polypectomy for adenoma(s). Methods: We identified 170 patients from our adenoma prevalence study who had an adenoma removed but did not return for surveillance colonoscopy within the expected timeframe. For each patient, the pathology was reviewed to confirm the need for surveillance. Patients were contacted by telephone and asked to rate their agreement (5-point Likert scale) with 14 statements, encompassing 4 dimensions of possible barriers: 1) financial (including lack or loss of insurance), 2) communication failures (including knowing how to set up the procedure), 3) compliance (including being too busy, or aversion to the procedure), and 4) understanding (of procedure’s importance). Results: 56 patients were able to be contacted and agreed to participate. Of those, 11 (20%) were AA and 26 (46%) were male. AAs were more likely than whites to cite "financial reasons" or "lack of insurance" for failure to return for surveillance (9% vs 2%). AAs were twice as likely to state they were unaware that they were supposed to come back (36% vs 16%), or claim that they had not been contacted (36% vs 16%) or re-referred (54% vs 23%). Women were five times more likely than men to "never want to have another colonoscopy’’ (20% vs 4%). AAs and women were more likely to agree that screening colonoscopy’s goal is ‘‘to remove polyps before they become cancer’’ and to agree that ‘‘colonoscopy after polyps are removed is important.’’ Conclusions: AAs who failed to return for surveillance colonoscopy in our study had a greater understanding of the purpose for surveillance than their white counterparts, but may have been more likely to expect to be contacted before returning; they were five times more likely to cite financial reasons for not returning. Women had a better understanding of the importance of surveillance colonoscopy than men, but 1 in 5 had an aversion to repeat procedures. These findings will help guide interventions aimed at improving adherence with surveillance colonoscopy after adenoma removal. Supported by a grant from The Center for Health Disparities Research
330 Prevalence of Colon Polyps O9 mm Detected By Colonoscopy Screening in Asymptomatic Hispanic and Asian/Pacific Islander Patients: Results from the National Endoscopic Database Brent Lee, David A. Lieberman, Jennifer L. Holub Compared to whites, Hispanics and Asian/Pacific Islanders have lower incidence and mortality from colorectal cancer (CRC). The purpose of this study was to determine if asymptomatic Hispanics and Asian/Pacific Islanders undergoing colonoscopy screening also have lower age-adjusted rates of polyps O9 mm. Such data could inform future screening guidelines. Aims: To measure and analyze the prevalence and location of polyps sized O 9 mm in diameter in asymptomatic white, Asian/Pacific Islander and Hispanic patients who receive colonoscopy screening. Methods: Colonoscopy data were prospectively collected from the Clinical Outcomes Research Initiative (CORI) database, which represents a consortium of 67 adult gastrointestinal practice sites in the United States. Asymptomatic white (n Z 146,798), Hispanic (n Z 7,654), and Asian/Pacific Islander (n Z 1,567) patients who received screening colonoscopy from 2004 - 2007 were identified. Main outcome measures included prevalence and location of polyps O9mm, adjusted for age, gender, and family history of colorectal cancer in a multivariate analysis. Prior work has shown that polyp(s) O9 mm are closely associated with rates of advanced neoplasia. Results: There was no significant difference in prevalence of polyps O9 mm in white and Hispanic patients (6.2% vs 5.8%; pZ0.11; adjusted OR 0.94; 95% CI 0.85-1.03). Asian/Pacific Islander men and women had a lower prevalence of polyps O9 mm compared to white men and women (4.1% vs 6.2%; pZ0.0004; adjusted OR 0.67; 95% CI 0.52-0.86). When analyzed by decade of age, 60-69 year-old Asians had similar rates of large polyps compared to 50-59 year-old whites (see Table). Conclusion: Compared to whites, Hispanic men and women undergoing screening colonoscopy have a similar risk of polyps O9 mm, whereas Asian/Pacific Islanders have a lower risk. These data suggest that screening colonoscopy might be deferred until age 60 years in average-risk Asian/ Pacific Islanders. Further study is needed to confirm this finding. Prevalence of polyp(s) O 9 mm stratified by race and age.
Age(yrs)
Whites
!50 50-59 60-69 O70
383/8724 3678/69633 3149/44225 1954/24216
Asians (4.4%) (5.3%) (7.1%) (8.1%)
)Asian compared to Whites; p!0.01
www.giejournal.org
2/115 25/799 23/452 14/201
Hispanic (1.7%) (3.1%)) (5.1%) (7.0%)
17/506 190/3770 162/2279 74/1099
(3.4%) (5.0%) (7.1%) (6.7%)
Background: Acculturation, the change in behavior and values that occurs when an immigrant group comes into contact with another group, has been linked to important health outcomes such as coronary heart disease, and breast cancer. The association of acculturation with colon cancer risk is unknown. Our aim was to determine the risk of colonic lesions according to acculturation status among Hispanics. Methods: Consecutive patients referred for screening colonoscopy were prospectively enrolled. A detailed history was obtained, and a validated acculturation survey was administered along with a standardized dietary habit assessment to a subset of self-identified Hispanics. The number, size and location of each polyp were noted during endoscopy. The association between acculturation and adenomas of any size, including advanced neoplasms (adenomas R10mm or any adenoma with villous histology, high-grade dysplasia, or cancer) was assessed. Results: A total of 1,337 patients were enrolled of which 807 (58%) were Hispanic and served as the study cohort. The majority of these patients 749 (93%) were immigrants who had been in the US for 28 16 years. Mean age was significantly higher for immigrants compared to non-immigrants (58 9 vs 51 9; p!0.001), however BMI (27.9 5 vs. 28.1 6) and waist circumference (35 4 vs. 33 4) were comparable. The prevalence of colonic adenomas was higher but not significantly different between immigrants and non-immigrants (16% vs. 12%). In the subset of assessed immigrant Hispanics, age did not differ significantly between acculturated individuals and those who were not acculturated (59 8 vs. 59 9). However the prevalence of adenomas was significantly higher among the acculturated compared to the non-acculturated (25% vs. 11%, pZ0.046). Among the dietary factors assessed, acculturated Hispanics were more likely to consume pastries (72% vs. 55%; pZ0.047) and less likely to drink milk (69% vs. 86%; pZ0.036) compared to their non-acculturated counterparts. After controlling for age, gender, BMI, and number of years in the U.S., acculturation remained a significant predictor of colon pathology (ORZ4.5; 95% CI 1.2-18; pZ0.036). Conclusions: In this colon cancer screening population acculturation was a significant independent predictor of colon pathology among Hispanics, and was associated with a certain dietary profile. Further evaluation of acculturation-related risk factors may help address existing health disparities in colon cancer.
332 Time Trends and Racial Disparities in the Stage of Diagnosis of Esophageal Adenocarcinoma (EAC) in the United States Sachin B. Wani, Amit Rastogi, Mandeep Singh, Vikas Singh, John D. Keighley, Ajay Bansal, Prateek Sharma Background: The incidence of EAC continues to increase in US at an alarming rate. Overall 5-year survival rate for EAC is ~15% and is dependent on its stage of diagnosis. Aims: a)Study the trends in the stage of diagnosis of EACb)Assess racial disparities in the stage of diagnosis of EAC. Methods: The Surveillance Epidemiology and End Results (SEER) database of NCI was searched to identify all pts diagnosed with invasive EAC between January 1, 1976 and December 31, 2005. Data from 9 population-based registries were used to calculate incidence rates of EAC. Age-adjusted incidence rates, using the 2000 US standard, and 95% confidence intervals (CI) were calculated by gender and race (whites, blacks, and others) using SAS. These were calculated in six discrete 5-year time periods (1976-1980 through 2001-2005). Tumor stage was defined as SEER Historic Stage (local - confined to the esophagus; regional - invaded adjacent tissues or spread to regional lymph nodes; distant - metastasized or with distant lymph node involvement; unstaged). To assess for an overall change in the stage of diagnosis, c2 test of equal proportions across time was performed. To assess for a change in the individual stage of diagnosis, Cochran-Armitage test for trend were performed. Results: Between 1976 and 2005, 10,596 cases of EAC were diagnosed. Incidence of EAC/100,000 person-yrs increased from 0.51 in 1976-80 (95% CI 0.47-0.57) to 2.54 2001-05 (95% CI 2.45-2.63), an increase of 400%. In 2001-2005 (compared to 1976-1980) significantly higher number of local and regional EACs were diagnosed [33% increase in local tumors,32% increase in regional]; p for trend for both !0.0001 whereas lower number of distant cancers were diagnosed;p for trend Z0.0002. Significantly less tumors were unstaged in 2001-05 compared with 1976-80 (decline of 57%, p for trend !0.001). Incidence of EAC among whites increased 4-fold with significantly more tumors diagnosed at a local and regional stage; (39% increase in local tumors, 32% increase in regional, p for trend for both !0.0001; 6% decrease in distant, p!0.0005). The incidence of EAC among blacks also increased 2-fold but no significant change in the stage of diagnosis was noted. Conclusions: Updated results (up to 2005) of this population-based study suggest that the incidence rates of EAC continue to rise in whites and blacks. Currently, significantly more EAC are diagnosed at the local and regional stage along with a significant decrease in the distant and unstaged cancers in whites; however, a similar trend was not seen among blacks. Determination of factors driving these racial disparities in EAC stage diagnosis need to be explored.
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB105