CMPH Journal

Background

Physiologically, everyone is at risk of developing cancer in the United States. Hence, one in three persons will have cancer at some point per certain variables [6]. Deaths from cancer are second only to those caused by cardiovascular disease in the United States [1]. In 2020, 602,350 Americans lost their lives to cancer, according to the CDC [1]. These figures are deeply concerning given the high mortality rates among particular groups. Among the significant racial and ethnic groupings in the U.S., African American (AA) males and females had the highest cancer death rate, at 167 per 100,000 [1]. Cancer has far-reaching effects on a person’s life, including physical and mental wellbeing, economic standing, and social connections [7]. Cancer’s monetary toll on people, their loved ones, and healthcare systems is alarming. “The total cost of cancer care in the United States in 2019 was projected to be more than $21 billion,” according to a study of the available data [5]. Patients’ time and money are also factored into this total [5]. The disparities between different groups should be considered when estimating the total cost.

Particular cancers have associated prices which can be exorbitant when considering the low-income demographics most affected by these high-cost cancer types, as is the case with colorectal cancer in AA patients. According to a National Cancer Institute-sponsored analysis, in 2019, the colorectal cancer out-ofpocket cost ranked third highest at a national estimate of $ 1.46 billion [5]. Statistically, “colorectal cancer incidence and mortality have been higher in African American individuals compared to their non-Hispanic White counterparts [2].” Of note, the average AA household income is about half the average White household income. Hence, the economic effects of colorectal cancer for the average AA patient can be disproportionate to the average White patient [8]. Pathologically, colorectal cancer does not discriminate, but social inequalities in access to care can lead to poorer results for certain people than others. Considering these challenges, efforts to reduce cancer rates across the board must prioritize protecting the most disadvantaged.

While no “typical” kind of cancer exists in the United States, minorities receive a disproportionate share of medical attention. Recent years have seen an uptick in the concentration of researchers and doctors on the issues of preventing, diagnosing, and treating Colorectal Cancer. Acquired or inherited DNA or genetic mutations are the most common causes of colorectal cancer [9]. As a result of these changes, abnormal cells may proliferate excessively and form tumors in the colon’s or rectum’s inner mucosa [9]. Most forms of CRC start with benign lesions or adenomas that turn cancerous due to the combined activation of cancer genes and the inactivation of tumor suppressor genes [10]. Early screening can help identify such lesions to prevent progression and metastasis.

Most cases of colorectal cancer result from new, noninherited mutations in the DNA, which can occur at any time during a person’s life [9]. The incidence and severity of CRC have been linked to various factors, including but not limited to lifestyle habits, physical characteristics, food, gender, and ethnicity [9]. Inherited mutations cause colorectal cancer, and scientists are still trying to figure out how these risk factors work together. Professionals in the medical field are expected to be aware of and familiar with such associations to better counsel and care for patients who pose an exceptionally high risk within the larger community. CRC is not exclusive to any race or culture. However, it is more prevalent among African American adults [2]. In the African American community, colorectal cancer ranks third among the primary causes of cancer-related death [2]. African American males and females had the second highest incidence rate (46.8%) from 2014-2019, followed by Native Americans (49%). By the 1990s, the CRC incidence rates of African American men and women were lower than those of Non- Hispanic White men and women [2]. These disproportionately high rates of occurrence and mortality can be traced back to a combination of factors, including genetic predisposition, socioeconomic status, healthcare access disparities, rates of preventative screening, and the timing of treatment [2].

The American College of Gastroenterology recommends that people at average risk of developing CRC begin screening at 45 [10]. The best screening method, colonoscopy, is also the most intrusive and expensive. The fecal immunochemical test (FIT) is an at-home stool-blood test that is less expensive and invasive [4]. Guiac-fecal occult blood test, flexible sigmoidoscopy, and cat-scan colonography are more diagnostic methods [10]. While the Healthy People 2030 (n.d.) target for people aged 50-75 for CRC screening is 74.4%, the current national rate is 62.5%. Comparatively, the estimated CRC screening rate among AA adults aged 50-70 in 2019 was 68.5%, higher than the national average but still not quite commendable [11].

”Research on CRC racial disparities and the development of adaptable therapeutics to reduce CRC incidence and mortality rates in AAs have progressed in recent years [3]”. Increased CRC screening among AAs has been a focus in recent years. Studies suggest this population has poor colon cancer screening compliance due to cost, low health literacy, locality segregation, lack of healthcare access, mistrust of providers, and socio-structural barriers [4]. Contemporary efforts to address some of these barriers have focused on increasing knowledge and awareness among AAs through community outreach programs [4]. Other interventions have focused on utilizing technology and educational materials to increase health literacy regarding CRC risks, prevention, and health implications [12]. Despite the well-intentioned initiative, the frequency of early CRC screening has yet to show the desired increase in African American participation [13]. Moreover, the most studied interventions do not address the gender-based screening disparities in African American communities.

The studies regarding communal outreach interventions mostly showed more positive outcomes for AA women than men [14]. The literature inquiry needed to yield more data on the interventions that increase CRC screening adherence in AA males. This paper’s research and review aim to identify the barriers that interfere with early colorectal cancer screening and treatment in AAs through a literature review. Further, the efficacy of the efforts undertaken by healthcare professionals, healthcare organizations, and communities to modify barriers will be measured through careful analysis of the existing literature.

Current literature from 2019 through the present will be extracted and analyzed to answer three relevant questions in this paper. The first objective is identifying all statistically significant barriers to CRC screening in African Americans. Secondly, what interventions have produced measurable outcomes in increasing screening rates in the focus population? The third objective will be to identify gaps in the existing research on the topic and to recognize opportunities that further illuminate the barriers and associated interventions. The goal is not explicitly directed at African American adults, yet it still pertains to this special population. This study aims to determine whether there is evidence from the existing literature that modern interventions may overcome the barriers to screening to the extent necessary to achieve the goals of Healthy People 2030.

Because of the far-reaching consequences of cancer on individuals, communities, and society, a thorough study must be conducted to assess the status quo. Cancer is not just an individual’s concern, as seen by the economic and human toll it takes. Researchers, doctors, hospitals, health networks, state and federal agencies, and international health coalitions have their hands complete with cancer. We can easily understand the healthcare system’s shortcomings by looking at inequality. The fight against cancer has always received a disproportionate share of funding. However, certain groups of people have been left out of this effort. Cancer is a human problem, not a “White” or “Black” problem. This reality should inform both medical study and practice. Addressing healthcare injustice requires asking difficult questions and searching for creative answers. The research and ideas that can better this continuing conversation can only drive the lives of future generations.

Design and Methodology

Procedure

The decision to utilize a systematic review design was made because it is hierarchically the highest form of research, evidenced by its rigor, level of evidence, and analysis. The topic of interest was selected due to the investigator’s personal family experience with colorectal cancer. The study will be conducted to test three hypotheses: (H1) the major barriers to CRC screening in AAs are socioeconomic and systemic racism incorporating locational segregation, healthcare mistrust, and lack of access; (H2) community-based interventions are the most effective at increasing CRC screening rates in AAs, and (H3) the literature review will reveal the need for further research. The dependent variable is the CRC screening rate in AAs, and the independent variables are the interventions identified in the studies. With the topic selected, an initial search was done in the PROSPERO database of registered and published systematic reviews to eliminate duplicating similar studies on the topic. The investigation did not yield any studies that would result in duplication. The research was then broken down into steps of research and review of available literature on the topic, followed by systematic inclusion and exclusion of articles to undergo analysis. Using this information, the outline of the systematic review was broken down into the background, methodology and design, analysis and categorization, results, discussion, and conclusion.

Search Strategy

A comprehensive search was conducted on the topic of interest, colorectal cancer screening in African Americans, through databases such as PubMed, CINAHL, PROSPERO, and Medline. The search method used a combination of key search terms “colorectal cancer screening”, “CRC Screening AND African Americans,” “CRC screening interventions AND African American,” and “cancer screening interventions”. The search strategy had inclusion filters for articles that were published from 2019 to 2023, in English, peerreviewed, and open access or freely accessible online. The exclusion filters eliminated books, media, dissertations, newspaper articles, conference proceedings, and opinions. Further, selected articles’ reference lists were manually searched for additional relevant sources. Please see Figure 1 for the detailed list of exclusion and inclusion criteria.

Figure 1: Inclusion and Exclusion Criteria.

Study Selection

Searching peer-reviewed, English, freely accessible articles published from 2019 to 2023 yielded over 400 citations. These citations were narrowed down further to 163 by hand searching and eliminating studies that did not address colorectal cancer screenings. These studies were exported to a reference management application called RefWorks, which was used to eliminate any duplicate studies. After eliminating duplicate studies, the resulting 142 studies’ abstracts were hand searched and separated into folders based on studies that discussed CRC screening rates in AA, CRC screening rates in the general population, and CRC screening interventions. These three folders of studies were then reviewed. Studies that were not experimental or quasi-experimental, not based in the United States, and did not include AA participants were all filtered out and excluded. This process left 40 articles for manual review based on inclusion and exclusion criteria, as seen in Figure 1. The review of the abstracts and full texts of these eligible articles was done and the final review process yielded 20 final articles for analysis in this study.

Data Extraction

Analysis and review of the 20 included studies were conducted by hand search and extraction of the research type, background or conceptual framework, methodology, design, sampling, analyses, limitations, sample size, and the main findings of each study. To standardize the data, studies were then categorized based on the level of evidence, yielding the distribution into four different levels of evidence.

Quality Assessment

Using extracted data, studies were assessed for quality following the hierarchy of evidence levels guideline [15-16]; Evidence levels were assigned to studies based on the following features: research type, study design and methodology, analysis and results clarity, and study generalizability. Please see Figures 2 and 3 for the illustrations of the hierarchy guidelines adopted for quality assessment.

Figure 2: Illustrated guideline for study type categorization [16].