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By Elizabeth Thompson
Colorectal cancer, cancer that affects the colon and rectum, is personal for Charles Rogers.
Rogers recently went back home to rural North Carolina for a family cookout and found out one of his cousins was 17 years overdue for his colonoscopy.
The Sanford native and assistant professor of family and preventive medicine at the University of Utah School of Medicine has devoted his research to inequalities in men’s health.
“I gave him a little education about the importance of screening,” Rogers said.
Rogers’ research showed that Black men are disproportionately affected by colorectal cancer and North Carolina has multiple hotspots for early onset of the disease, according to a 2020 article he co-authored that was published in the American Journal of Cancer Research.
As a Black man from rural North Carolina Rogers knows those disparities aren’t just numbers. They could be people he loves.
“Don’t you want to be around here for your grandkids?” Rogers asked his cousin. Then he gave his cousin his phone number and told him to send him a screenshot after he received his test and he’d give him $100.
Colorectal cancer is the same disease that killed Black Panther actor Chadwick Boseman last August at just 43 years old. Boseman’s death helped raise awareness of the dangers of letting colorectal cancer — which is highly treatable when discovered early — go undetected.
Much still needs to be done, Rogers said.
‘No longer an old man’s disease’
For years, the traditional age to start screening for colorectal cancer was 50, but research suggests that people are getting sick younger. The incidence of colorectal cancer has increased by almost 15 percent from 2000-2002 to 2014-2016.
“The narrative has to change,” Rogers said. “That it’s no longer an old man’s disease. Women can get it too. A lot of people just think it’s something old white men get, and you don’t have to get screened until your fifties.”
That increased incidence is what prompted the U.S. Preventive Services Task Force to recently lower its recommendation for screening to include adults starting at age 45 in May. This follows the 2018 change the American Cancer Society made of lowering the screening benchmark to the same age, 45.
Rogers’ analysis of CDC mortality data of men 15 to 49 years old diagnosed with colorectal cancer from 1999 to 2016 found that in specific hotspot counties, mostly in the South, these men had a 24 percent greater chance of dying from the disease.
Twenty-one North Carolina counties were found to be hotspots: Bertie, Burke, Caldwell, Caswell, Cleveland, Edgecombe, Granville, Halifax, Jackson, Martin, Moore, Nash, Northampton, Person, Richmond, Robeson, Rockingham, Scotland, Vance, Warren and Wayne.
Doctors and researchers are still trying to pinpoint what exactly makes people more at risk for colorectal cancer. Rogers’ analysis showed a strong correlation with smoking and colorectal cancer, but there’s more to it than that, the social determinants of health also play a big role, he said.
Social determinants of health
Ronny Bell, professor of social science and health policy at Wake Forest School of Medicine and director of the Office of Cancer Health Equity studies the social determinants of health, the ways we see health disparities affecting populations due to factors ranging from race, ethnicity and poverty status to geography and gender.
“It’s really looking at the upstream factors that contribute to the disparities that we see in numerous health outcomes,” Bell said, “because we know that those health outcomes don’t flip a switch and then all of a sudden you have cancer, you have heart disease. There’s something that’s occurring, years down the road, and those factors are embedded in the places we live, the places we worship, the places that we congregate with other people.”
Living a healthy lifestyle by eating a healthy diet, being physically active, avoiding tobacco and excessive alcohol use are things that not only would prevent colorectal cancer, but a variety of other diseases, Bell said.
But that is sometimes easier said than done.
“You can’t turn the TV on now without seeing the $5 meal deal or these very cheap ways of getting high calorie foods,” Bell said. “ … By the same token, if I’m having to make decisions about how to feed my family on a limited amount of financial resources. I may choose that option.”
There are also geographical areas that have sparse options for affordable and good quality fresh food, known as food deserts.
Rogers said he grew up on processed foods, like bologna, potted meat, Treet — “the first cousin of Spam” — and fried foods.
“It’s okay to eat those things sometimes,” Rogers said, “but they can’t be every day. You got to take the little stuff that you can to improve your health.”
Getting to the root causes of colorectal cancer could require restructuring communities to have access to affordable, quality grocery stores and spaces to exercise, Bell said.
But curbing deaths from colorectal cancer is as simple as routine screening. When found at an early stage, colorectal cancer has a five-year relative survival rate of about 90 percent, according to the American Cancer Society.
A 2020 study from Epic Health Research Network found that the COVID-19 pandemic caused a 86 percent to 94 percent drop in preventative cancer screenings across the country.
The North Carolina Department of Health and Human Services received five years of funding from the Centers of Disease Control and Prevention in September 2020 to partner with local community health centers, known as federally qualified health centers, to increase screenings.
“Our aim is to remove barriers to screening and treatment for people in the higher-risk age range (50 to 75), including those who may not have access to health insurance, and move North Carolina further toward the national testing goal of screening 80 percent in every community,” said Susan Kansagra, Section Chief for Chronic Disease and Injury Prevention in the Division of Public Health, in a press release at the time.
North Carolina’s community health centers provide primary care to many of the state’s underserved, including those who are uninsured, serving 610,000 patients in 2019. Fully a third of those patients were African American and 30 percent were of Latino or Hispanic ethnicity. Nonetheless, only 46 percent of patients 50 to 75 years old were screened for colorectal cancer, the press release said.
Low screening rates are due to everything from not enough awareness, to stigma surrounding colonoscopies, one procedure used to identify colorectal cancer, and a perception that the preparation for the procedure is onerous and uncomfortable.
A colonoscopy, an exam that entails a long tube being inserted into the rectum to view the colon, requires about a day and a half of time from preparation to recovery. People in rural areas may also have to travel to get to a doctor who can perform the procedure and take a day or two off from work between the prep and the procedure itself.
“You talk to people, particularly men who just say, ‘I’d rather not know… I don’t feel like I can make myself vulnerable to know if I have a disease or not,’” Bell said.
New ways to look
More recently, there are alternatives for screenings that are less invasive and time-consuming, and are cheaper.
The UNC Lineberger Comprehensive Cancer Center has been working to improve screening for colorectal cancer through its Scaling Colorectal Cancer Screening through Outreach, Referral and Engagement (SCORE) Initiative. The SCORE program uses fecal immunochemical tests (FIT) to screen patients in the comfort of their own homes, said Alison Brenner, SCORE co-investigator.
When patients get a FIT test, they get a small envelope with a tissue they lay over the toilet when they are having a bowel movement. Then, they place the stool they collect in a plastic tube, put it in a biohazard bag and send it to the lab for processing where it will be tested for blood.
Should the test show blood, that patient would have to get a colonoscopy. For the vast majority of people who will not find blood in their stool, they are done with screening for a year.
The study focuses on people 50 to 75 years old, Brenner said, but the program is doing a smaller study on a group of 45 to 49 year olds.
SCORE has partnered with Roanoke Chowan Community Health Center and Blue Ridge Health to serve North Carolina’s northeastern and western counties, Brenner said.
“Colonoscopies are a lot of work,” Brenner said. “We have to spend a day to a day and a half prepping your body for a colonoscopy. It is an invasive procedure. They’re sticking an endoscope inside of your colon and looking around, there’s a small risk of adverse outcomes. It’s also very expensive and that’s probably the most important thing, FIT testing is very inexpensive.”
Signs of colorectal cancer to be aware of, Rogers said, include blood in your stool, bloating unrelated to the menstrual cycle, losing weight out of nowhere and inability to have a bowel movement in a number of days that is irregular.
If you are a younger person worried about colorectal cancer, Brenner recommended you talk to your doctor.
“I think for somebody under 45 that has concerns, any physician would direct them towards a colonoscopy,” Brenner said. “Be it substantial family history, GI bleeding, etc., they would be directed to a colonoscopy.“