Understanding Disparities in Colorectal Cancer Care

Intro Thanks for listening to this podcast episode from courto ads Independent medical education. This episode is supported by an independent educational grant from Bayer. Speaker 2 Hello and welcome back to another episode of The Oncology Brothers as we continue with our GI series. I'm Rahul Gosain and along with my brother and Co host Rohit Gosain. Today we're going to explore the needs of different patient populations in colorectal cancer. This episode is going to be very special. Speaker 3 In our clinic, every single patient and family member in that room is seeking hope. With all the data and new treatment options and potential side effects, we need to tailor our discussion to the patient in front of us as their needs, pathology, expectations and what matters to them is different. A lot of this unfortunately gets lost, especially for our patients of color or other minority backgrounds. Different socio economic backgrounds also play a major role independently in patients outcome at large to. Speaker 4 Focus. Speaker 3 On these disparities, we are joined by Doctor Tony Bicayasaab, a medical encouragist who is the leader of gastrointestinal program at the Mayo Clinic, and Miss Danine Richmond, a patient, a patient advocate and a nurse by training. And she's also the president of a large Community Hospital in Maryland. Tony and Danine, thank you so much for joining us later. Speaker 5 Yeah, great to be here. Speaker 3 Denain, you wear so many hats, but given our focus today on different patient populations in colorectal cancer, would you be OK to share your recent journey as a patient? Denain’s Journey Yes, and it is definitely recent. So I can. Speaker 5 Easily talk about it so there's a date that will be forever X. Speaker 1 To my brain, and that is February 15th, 2023 when I woke up from a colonoscopy and heard that I had rectal cancer and that. Speaker 5 Rest of that day was a blur, but. Speaker 1 You know you. Speaker 5 You you face. Speaker 1 Your humanity, your mortality and wonder what is it going? Speaker 5 To be like, So what was it like over the last year? Speaker 1 I had chemotherapy. I had radiation therapy. I had. Speaker 5 Surgery. Speaker 1 I had more chemotherapy and then just had my last. Speaker 5 Surgery a little. Speaker 1 Over a month ago to finally put everything back together and make me whole again. Speaker 5 And so I'm very pleased to share that at. Speaker 1 This time I have no evidence of disease and have moved into that next phase of surveillance, but it has really been a year. Speaker 2 Janine, thank you so much for sharing your personal experience. We're thrilled to hear that you are recovering well. As an oncologist, we have to be mindful of a few factors at play with any cancer diagnosis including race, ethnicity, age, gender role had brought up socio economic status and studies continue to show who are outcomes in African Americans, black Americans, Hispanics or patients with low socio economic status when it comes to colorectal cancer. Access to Colorectal Cancer Screening and Treatments So it is important for us and it is important to be cognizant of these outcomes so that we can adapt our approach to these different patients. Tony, from your perspective, what disparities exist in access to colorectal cancer screening and treatments? Speaker 5 Yeah I know and and I'm glad to be on the discussion today. And again you know the most important aspect of cancer care is preventing it. We can prevent it. That would be best and and I I think you know with colon cancer, colorectal cancer at least early screening, perhaps some level of prevention, but early screening we know is E to get patients to to a potential cure, early cure or even prevention. And so it's very important to focus on that discussion. As you've alluded to, the burden of colorectal cancer varies quite a bit across socio economically disadvantaged groups and it happens that many of these groups are in those racial ethnic groups. The burden of colorectal cancer varies across socioeconomically disadvantaged groups So the under what we call the underrepresented minorities, I mean it's astounding to see the differences between, you know, blacks and whites. It's well documented. You know, African Americans, you know, have a higher incidence of colorectal cancer. They tend to have it at a younger age and they have a higher mortality rate and a lot of it has to do with the fact that they present later in the diagnosis. They don't have the same access for for many reasons and we'll go through these reasons to screening. I I think screening overall is problematic across you know the the US and and and the rest of the world where only half of the patients actually or half the population eligible would get the screening. But it's it's further accentuated when we start looking at you know, underrepresented minorities. I mean one example is if we, we look at Asian Americans, you know this is the second most common cancer in in Asian Americans. And when you look at the colorectal screening rate in in Asian Americans in the US, it's actually the lowest of all groups. So some of this is down to we think I mean when we look at racial disparities, perhaps genetic predisposition, some lifestyle, but I think mostly access to high quality care for these patients. So you know when starting to think about the causes, I mean let's take for example African Americans, so black patients, there's definitely a level of distrust in the system and that is based on on you know historic perspective and so, so, so they present later and I think this is where it's important for us as healthcare providers to rebuild that trust with, with our patients, with our African American black patients, with all patients but specifically that that group of patients. So they're not coming forward early, they're not getting for the most, they're not getting you know essentially their colonoscopies. Now, there are other factors also. In the US, you know, insurance coverage can be a barrier, especially again for socio, economically disadvantaged proof. You know, think about it. Even so, if you go to someone whose likelihood depends on the hourly work schedule, to ask them to actually lose a whole day of work can mean, you know, bringing bread to the table for their families versus not. If if we look at the countries such as Canada with the universal healthcare, the rate of colonoscopy is actually our screening is no better than the United States. So I don't like to simplify the discussion and say, well, you know what, we'll just make it. We'll make, we'll make it just available to everyone. That by itself does not solve the issue. We have to think about everything else. Trust cultural sensitivities. We also have to understand Access. Speaker 4 Thank you so much for covering all that it is. Speaker 3 Extremely important for the points that you raised about socioeconomic status, racial disparities, especially when you gave the example of them, these young people missing out their work, especially when they are the sole earners of family. So those are important things that we as physicians, as a healthcare system need to understand and listen to the patients and their needs. Deneen, that was from Tony or from physician or medical standpoint, you're from patient perspective. Challenges in screening for colorectal cancer What do you think some of the challenges around screening for colorectal cancer that we face from patient or patient advocate or even a president from a community practice standpoint? Speaker 5 Sure. So I think that it's a topic. Speaker 1 You know, when we think about what people are comfortable talking about, not everyone if you don't have that relationship. Speaker 5 With a provider. Speaker 1 You're not going to necessarily be comfortable going into an appointment and talking about changes in your bowel habits or seeing blood in your stool or, you know, all of those other symptoms that we know people may experience. Speaker 5 But they there's. Speaker 1 Stigma we just don't go around talking about. Speaker 5 How our bowel habits I think that that is a barrier. Speaker 1 I also think and I've talked to many other. Speaker 5 Folks, who will? Speaker 1 Say, you know, there's a lot of mystery. I would put it around colonoscopies and people just not understanding, you know, they think it's going to be painful or, you know, not just not understanding what's involved in having that. Speaker 5 Type of procedure. Speaker 1 And you know. Speaker 5 As I'd say to people. Speaker 1 Look, the most uncomfortable thing is going to be the. Speaker 5 The the prep, the day. Speaker 1 Before that, you're going to have to get through, but you know you. You're not going to have pain during the procedure. You won't even be aware. Speaker 5 You've got your that you've had the. Speaker 1 Procedure and afterwards there's no pain, but that's not widely understood by people, so I think that is another. Speaker 5 Barrier that stops. Speaker 1 People from moving forward. And then I think it's just trust and being heard, I mean, I think particularly in communities of color. Barriers to screening for colorectal cancer That is a. Speaker 1 Big barrier around not just screening. Speaker 5 For colorectal. Speaker 1 Cancer, but around accessing and getting. Speaker 5 Good quality health. Speaker 1 You know, culturally sensitive. Speaker 5 Healthcare as a whole. So if your. Speaker 1 Voice isn't heard. You know, in my situation, you know, I had had my screening, colonoscopy and everything was fine. And then I had some symptoms years following that, several years following that and I was originally, I think. Speaker 5 Appropriately so. Speaker 1 Being treated for hemorrhoids, but it got to a point where I knew that something else was going on in my body. Speaker 2 Jeanine, thank you so much for bringing all that. A few things to dissect 1, educating patients around the procedure, I think is so important. As a physician, Tony, Ruth and I can talk about it, but I would think that patients want to hear from patients. That's why these conversations are so important. Otherwise it's a biased opinion saying oh go get your screening colonoscopy when it's coming from your medical oncologist. And again the other thing that you brought up is at times patients bringing up something and that's not taking seriously that ends up being more profound again in patients of color or with low socio economic status. There are data out there supporting that. So taking a step back, as a medical oncologist, we need to be more mindful of addressing each and every patient concern and making sure we're mindful of what the long term outcomes can be. Speaker 1 It's so important when we talk about building that trusting relationship that we don't discount what someone is sharing. It may be. Speaker 5 Totally. Speaker 1 Irrational. But to them it's real. And if it's discounted or not acknowledged and addressed, you know. If it's a myth or a misperception, address it in plain English. No, you know, not with a lot of medical jargon. But but. But. Speaker 5 Allow that. Speaker 1 Person to. Speaker 5 Be able to be heard. Speaker 1 And get answers. Speaker 5 To the questions. Speaker 1 That they may have. Speaker 2 Oh, absolutely. Educating around that is important. One thing that we get pushed back is around the time that we have to spend either through Emrs or face to face with patients. But all this is very important, Tony. Hearing all these concerns, $1,000,000 question ends up being we're seeing an alarming trend of colorectal cancer in young patient population. Raising awareness of colorectal cancer in African American and Hispanic communities Again, you brought up some stats for African American or Black Americans having a high risk disease or greater mortality. What are some effective strategies we can consider to educate or raise awareness about colorectal cancer within these different communities? Speaker 5 Yeah and you know one other dimensions that I think we need to add, You know we are a a multi ethnic country, a melting pot and language can be a barrier for many of our communities. I think about the Hispanics, I think Hispanic non whites specifically but Hispanics overall you know that that certainly to reach them in addition to be culturally sensitive language can be a significant barrier but also to bring the issues of trust in others. So overall I think bringing awareness is a very complex and multiple issues but and we have to hit all these points to bring awareness. But as you brought up, one of the biggest concerns we have today is what we call an epidemic of younger, younger patients with cancer and specifically with colorectal cancer. Many reasons for that we think although none of that at this point of time has been you know documented clearly there are hypotheses is it the microbiome lifestyle changes but it does seem to hit even at a higher rate blacks. African Americans. And so although at this point of time the age for your first colonoscopy for normal for average risk is 45, many times we advocate for you know African Americans actually a lower age screening perhaps 40. So I think education is important and again keeping in mind the cultural sensitivities, the trust issues, access issues, meeting patients where they at and and raising awareness about colorectal cancer within all, all and I say all our communities, you know we have to remove that stigma that myth that the screening procedures is, is invasive. There are alternative options as well, but I still think colonoscopy is the gold standard. Now that said, you know there there's data that supports flexible flex, SIG and FOBT stool tests. So we have to to make sure that they emphasize, you know the the points that for for all patients that colorectal cancer is preventable and if caught early, not only is treatable but curable. Our best chance at a cure is for it to be caught early. It's also very important to, you know, focus on families. So with African Americans and with others going to churches, going to places of worship, I mean, this is where you can talk actually more openly. And and we have, again, to be culturally sensitive. Like you said, I don't want the oncologist to go talk to people about screening. I want to make sure that I'm one of many voices. But the voice that's closest to the community, that's closest to understanding the disease is probably the best motivator, including touching their families, right. I mean, we all know that the spouse, a loved one is going to say you better go get that colonoscopy. So we want to talk to everyone, not just to the person. You know, being healthy is great. You want to continue being healthy and live a long life. So being healthy and feeling relatively good is does not replace the need for screening. I do think also that we need to educate. That's on us, you know, our many of our colleagues. Speaker 3 But Rahul and I very well know that because it took us forever to sort of tell our parents and get that across and have their colonoscopy done, because again, that education is certainly lacking. Sudanine, from your perspective as a president of Community Hospital and also a patient advocate, your thoughts on how we can raise awareness and also build trust with different patient groups? Raising awareness and building trust with different patient groups So I think that we have to. Speaker 1 Use multiple different. Speaker 5 Strategies and voices to raise. Speaker 1 Awareness and build trust and. Speaker 5 It makes me. Speaker 1 Think about some. Speaker 5 Strategies that we used just a few short years ago. Speaker 1 When we were all trying to convince everyone. Speaker 5 Of the benefits. Speaker 1 Of getting vaccinated against. Speaker 5 COVID and we. Speaker 1 All know that there was lots of mistrust in communities, particularly communities of color. Yet. Speaker 5 Those were the. Speaker 1 Very communities, at least in my. Speaker 5 Geographic area. Speaker 1 Where we were seeing the highest number of rates, hospitalizations and deaths. Speaker 5 So part of our strategy and we've. Speaker 1 Leveraged this in other ways since then and I talked to other community groups. Speaker 5 About this is. Speaker 1 You know using? Speaker 5 Trusted voices, so educating people. Speaker 1 You know, sometimes we talk about people who have lived experience in the community, but using people. Speaker 5 Who? Speaker 1 Are trusted already in that community. So it was already brought up about churches and the faith-based community. So we had one of the, you know, prominent pastors in our community come to our hospital. Speaker 5 Get his vaccine, videotape it, talk about it. You know, he was all. Speaker 1 Over social media. Speaker 5 And so I think that that strategy of trusted voices. Speaker 1 You know, we we ran into Barber shops and beauty salons, you know, gave them basic education and training and then used them to talk to their clients that are sitting in their chairs getting their hair done. Speaker 5 So I think that that is a. Speaker 1 Strategy. You know that I think we really need to think about. I think that. Speaker 5 We also have. Speaker 1 To, you know, starting very young. Speaker 5 Educate people about. Speaker 1 Different aspects of health, including, you know, what things to be. Speaker 5 To watch out for what? Speaker 1 Things to make sure you. Speaker 5 Talk to your. Speaker 1 Doctor about Don't be embarrassed about it. Don't. Speaker 5 Be worried about. Speaker 1 What they're going to think about. Speaker 5 You if you. Speaker 1 Go in and say I have blood in my stool or whatever symptom you might be having. So having those conversations and then I I love the thought of, you know, leveraging families. Speaker 5 You know, that's. Speaker 1 Why I share my? Speaker 5 Experience of what it's like. Speaker 1 To get a colonoscopy. Speaker 5 So I think we just got to think about all of those ways that we really. Speaker 1 Think. Speaker 5 About our healthcare. Speaker 1 Extenders and these are. Speaker 5 Folks who? Speaker 1 You know, haven't gone through formal training, but. Speaker 5 Really can be. Speaker 1 Some of our. Speaker 5 Biggest health advocates. Speaker 1 With their circle, their network. Speaker 5 Their circle of. Speaker 1 Friends and family and even beyond that out in our communities. Speaker 2 Janine, thank you so much for sharing those ideas. OK, So far we focused on screening and getting the diagnosis. Does age play a role in choosing a treatment option for colorectal cancer? So let's say we have made the diagnosis. Tony, does age play a role in selecting a treatment option here? Speaker 5 The short answer is, in the absolute sense, no. Overall, colorectal cancer isn't just a disease of the elderly, but overall in terms of treatment options, in terms of the genomic genetic composition of the cancer, for most patients, it is not dependent on a gender or age, and treatments are more tailored to the drivers of the cancer. Now that said, you know it is often a misconception that because someone has and inherited risk for cancer, they will present at their younger age. The reality is actually most patients with an inherited risk present at at a later age. Now when we think about younger patients, we tend to be a little bit more aggressive. And when I say younger patients that's younger than 70 or 75 or healthy 75 can withstand again in in measured ways aggressive treatment, 1 indicated and if indicated, then if the patient is able to. So again using using age is, is with caution. Now someone older than 75, we have to be very careful about about, you know, more aggressive chemotherapy. I'm thinking about triplets perhaps or even EGFR inhibitors and others. I mean, we have data consistently now suggesting that, you know, someone older than 75 may not benefit and perhaps we'll see more toxicities from a doublet. Versus a single agent chemotherapy. So in some, some ways you know age may may play a role especially when it comes to the chemotherapy. When it comes to biologic and biologic targets, not as much these these are tailored and and hopefully as we move away more and more from chemotherapy, although it's not going away, we move away from extended periods of chemotherapy, you know then then we'll have actually more and more access to to better targeted or immunotherapeutic agents. But again, age in that sense does not alter the composition of the tumor as much. Speaker 3 Well, we are nearing the end, Tony. Understanding the needs of different patients in colorectal cancer Any last thought for our listeners on understanding the needs of different patients in colorectal cancer? Speaker 5 Yeah. No, I think, I think we, we really have to keep on hammering the notion that it's not just colorectal cancer, all cancer, but specifically colorectal cancer is not just a disease of the elderly. And I think you know we have to bring this awareness and the importance of appreciating you know what symptoms to look for. So we need to remember that also that patients overall are working, juggling family commitments. So for the younger patients, when they get diagnosed, when they go through their surgery, when they go through their treatment, there's a lot of gaps in their employment, there's a lot of gaps in supporting their families. And often times frankly a lot of younger patients are reluctant and especially again from under represented minorities are reluctant to get a colonoscopy because I'd rather not know about it. So I think overall education, improving access to screening programs and part of education is essentially, you know, removing some of the stereotypes around the risks of colonoscopy. So we have to find different allies from the community, from our own community of physicians, but mostly from the community that represent all these patients, culturally sensitive, language sensitive and be able to rely on on bringing this information closer to home. Speaker 4 Thanks so much for covering all the points there. How we can continue to do better Tony Deneen, your thoughts as a patient, patient advocate and in. Speaker 4 Healthcare Executive on. Speaker 3 How we can continue to do better? Speaker 5 So I would. Speaker 1 Say from a patient perspective, starting there, you know. Listen to your body. Recognize that you know. Speaker 5 Your body, your. Speaker 1 Symptoms What feels right and what doesn't? Better than anyone else? Speak up. Speaker 5 Don't be afraid, there's. Speaker 1 Nothing that you're going to tell a, a doctor or any. Speaker 5 Other healthcare provider. Speaker 1 That's going to be that they're going to look at you a certain way or that's embarrassing. They need to know. Speaker 5 Exactly what's? Speaker 1 Going on so that they can diagnose and. Speaker 5 Treat you appropriately. Speaker 1 And then I think that on the, you know, on the. Speaker 5 Provider side whether? Speaker 1 It's on the direct clinician side or even on the administrative side. You know we all have to commit to 1 acknowledging that. Speaker 5 These disparities that we've talked about today exist. Speaker 1 And be willing to be. Speaker 5 Part of the. Speaker 1 Solution and Sometimes the solutions aren't easy and sometimes the solutions aren't totally in our own control. But we can collaborate and partner with others. We can collaborate and partner with our patients and and really make a difference because you know, I hope that a year from now, five years from now, 10 years from now that we aren't having these same conversations around, you know, differences and outcomes because we're talking about someone's human life. That's really what it all comes down to at the end of the day. Speaker 4 Thank you, Deneen and Tony. Speaker 3 Thank you so much for joining us today and raising awareness and education about this very important topic. Deneen, we all wish you the best with ongoing surveillance and your journey ahead. Thank you for all the listeners to tuning in. Thank you. Speaker 1 If you like this episode and want to find out more on GI Oncology, then look on the Oncology Medical Conversation Podcast under the account of court to add medical education for other interesting episodes. Also, don't forget to rate this episode, subscribe to our channel or inform your colleagues about it. Thank you for listening and see you next time. This podcast is an initiative of CORE to ADD and developed by GI Connect, a group of international experts working in the fields of GI Oncology. The views expressed are the personal opinions of the experts. They do not necessarily represent the views of the experts, organizations or the rest of the GI Connect Group. For expert disclosures on any conflict of interest, please visit the Corruette website.