Editor's Note: 

As we all strive to improve the rate of colorectal cancer screening, it is important to acknowledge that barriers exist that prevent screening uptake.

Importantly, these barriers often vary between specific population subsets. In this month’s In Focus article, brought to you by The New Gastroenterologist, the members of the AGA Institute Diversity Committee provide an enlightening overview of the barriers affecting underserved populations as well as strategies that can be employed to overcome these impediments. Better understanding of patient-specific barriers will, I hope, allow us to more effectively redress them and ultimately increase colorectal cancer screening rates in all populations.

Bryson W. Katona, MD, PhD
Editor in Chief, The New Gastroenterologist

Despite the positive public health effects of colorectal cancer (CRC) screening, there remains differential uptake of CRC screening in the United States. Minority populations born in the United States and immigrant populations are among those with the lowest rates of CRC screening, and both socioeconomic status and ethnicity are strongly associated with stage of CRC at diagnosis.^1,2 Thus, recognizing the economic, social, and cultural factors that result in low rates of CRC screening in underserved populations is important in order to devise targeted interventions to increase CRC uptake and reduce morbidity and mortality in these populations.

Vidyard Video

What are the facts and figures?

The overall rate of screening colonoscopies has increased in all ethnic groups in the past 10 years but still falls below the goal of 71% established by the Healthy People project (www.healthypeople.gov) for the year 2020.³ According to the Centers for Disease Control and Prevention ethnicity-specific data for U.S.-born populations, 60% of whites, 55% of African Americans (AA), 50% of American Indian/Alaskan natives (AI/AN), 46% of Latino Americans, and 47% of Asians undergo CRC screening (Figure 1A).⁴ While CRC incidence in non-Hispanic whites age 50 years and older has dropped by 32% since 2000 because of screening, this trend has not been observed in AAs.^5,6

The incidence of CRC in AAs is estimated at 49/10,000, one of the highest amongst U.S. populations and is the second and third most common cancer in AA women and men, respectively (Figure 1B).

Similar to AAs, AI/AN patients present with more advanced CRC disease and at younger ages and have lower survival rates, compared with other racial groups, a trend that has not changed in the last decade.⁷ CRC screening data in this population vary according to sex, geographic location, and health care utilization, with as few as 4.0% of asymptomatic, average-risk AI/ANs who receive medical care in the Indian Health Services being screened for CRC.⁸

The low rate of CRC screening among Latinos also poses a significant obstacle to the Healthy People project since it is expected that by 2060 Latinos will constitute 30% of the U.S. population. Therefore, strategies to improve CRC screening in this population are needed to continue the gains made in overall CRC mortality rates.

The percentage of immigrants in the U.S. population increased from 4.7% in 1970 to 13.5% in 2015. Immigrants, regardless of their ethnicity, represent a very vulnerable population, and CRC screening data in this population are not as robust as for U.S.-born groups. In general, immigrants have substantially lower CRC screening rates, compared with U.S.-born populations (21% vs. 60%),⁹ and it is suspected that additional, significant barriers to CRC screening and care exist for undocumented immigrants.

Another often overlooked group, are individuals with physical or cognitive disabilities. In this group, screening rates range from 49% to 65%.¹⁰

Finally, while information is available for many health care conditions and disparities faced by various ethnic groups, there are few CRC screening data for the LGBTQ community. Perhaps amplifying this problem is the existence of conflicting data in this population, with some studies suggesting there is no difference in CRC risk across groups in the LGBTQ community and others suggesting an increased risk.^11,12 Notably, sexual orientation has been identified as a positive predictor of CRC screening in gay and bisexual men – CRC screening rates are higher in these groups, compared with heterosexual men.¹³ In contrast, no such difference has been found between homosexual and heterosexual women.¹⁴

What are the barriers?

Several common themes contribute to disparities in CRC screening among minority groups, including psychosocial/cultural, socioeconomic, provider-specific, and insurance-related factors. Some patient-related barriers include issues of illiteracy, having poor health literacy or English proficiency, having only grade school education,^15,16 cultural misconceptions, transportation issues, difficulties affording copayments or deductibles, and a lack of follow-up for scheduled appointments and exams.^17-20 Poor health literacy has a profound effect on exam perceptions, fear of test results, and compliance with scheduling tests and bowel preparation instructions^21-25; it also affects one’s understanding of the importance of CRC screening, the recommended screening age, and the available choice of screening tests.

Even when some apparent barriers are mitigated, disparities in CRC screening remain. For example, even among the insured and among Medicare beneficiaries, screening rates and adequate follow-up rates after abnormal findings remain lower among AAs and those of low socioeconomic status than they are among whites.^26-28 At least part of this paradox results from the presence of unmeasured cultural/belief systems that affect CRC screening uptake. Some of these factors include fear and/or denial of CRC diagnoses, mistrust of the health care system, and reluctance to undergo medical treatment and surgery.^16,29 AAs are also less likely to be aware of a family history of CRC and to discuss personal and/or family history of CRC or polyps, which can thereby hinder the identification of high-risk individuals who would benefit from early screening.^15,30

The deeply rooted sense of fatalism also plays a crucial role and has been cited for many minority and immigrant populations. Fatalism leads patients to view a diagnosis of cancer as a matter of “fate” or “God’s will,” and therefore, it is to be endured.^23,31 Similarly, in a qualitative study of 44 Somali men living in St. Paul and Minneapolis, believing cancer was more common in whites, believing they were protected from cancer by God, fearing a cancer diagnosis, and fearing ostracism from their community were reported as barriers to cancer screening.³²

Perceptions about CRC screening methods in Latino populations also have a tremendous influence and can include fear, stigma of sexual prejudice, embarrassment of being exposed during the exam, worries about humiliation in a male sense of masculinity, a lack of trust in the medical professionals, a sense of being a “guinea pig” for physicians, concerns about health care racism, and expectations of pain.^33-37 Studies have reported that immigrants are afraid to seek health care because of the increasingly hostile environment associated with immigration enforcement.³⁸ In addition, the impending dissolution of the Deferred Action for Childhood Arrivals act is likely to augment the barriers to care for Latino groups.³⁹

In addition, provider-specific barriers to care also exist. Racial and ethnic minorities are less likely than whites to receive recommendations for screening by their physician. In fact, this factor alone has been demonstrated to be the main reason for lack of screening among AAs in a Californian cohort.⁴⁰ In addition, patients from rural areas or those from AI/AN communities are at especially increased risk for lack of access to care because of a scarcity of providers along with patient perceptions regarding their primary care provider’s ability to connect them to subspecialists.^41-43 Other cited examples include misconceptions about and poor treatment of the LGBTQ population by health care providers/systems.⁴⁴

How can we intervene successfully?

Characterization of barriers is important because it promotes the development of targeted interventions. Intervention models include community engagement programs, incorporation of fecal occult testing, and patient navigator programs.^45-47 In response to the alarming disparity in CRC screening rates in Latino communities, several interventions have been set in motion in different clinical scenarios, which include patient navigation and a focus on patient education.

Randomized trials have shown that outreach efforts and patient navigation increase CRC screening rates in AAs.^48,54,55 Studies evaluating the effects of print-based educational materials on improving screening showed improvement in screening rates, decreases in cancer-related fatalistic attitudes, and patients had a better understanding of the benefits of screening as compared with the cost associated with screening and the cost of advanced disease.⁵⁶ Similarly, the use of touch-screen computers that tailor informational messages to decisional stage and screening barriers increased participation in CRC screening.⁵⁷ Including patient navigators along with printed education material was even more effective at increasing the proportion of patients getting colonoscopy screening than providing printed material alone, with more-intensive navigation needed for individuals with low literacy.⁵⁸ Grubbs et al.reported the success of their patient navigation program, which included wider comprehensive screening and coverage for colonoscopy screening.⁵⁹ In AAs, they estimated an annual reduction of CRC incidence and mortality of 4,200 and 2,700 patients, respectively.

Among immigrants, there is an increased likelihood of CRC screening in those immigrants with a higher number of primary care visits.⁶⁰ The intersection of culture, race, socioeconomic status, housing enclaves, limited English proficiency, low health literacy, and immigration policy all play a role in immigrant health and access to health care.⁶¹

Courtesy Aline Charabaty

Therefore, different strategies may be needed for each immigrant group to improve CRC screening. For this group of patients, efforts aimed at mitigating the adverse effects of national immigration policies on immigrant populations may have the additional consequence of improving health care access and CRC screening for these patients.

Data gaps still exist in our understanding of patient perceptions, perspectives, and barriers that present opportunities for further study to develop long-lasting interventions that will improve health care of underserved populations. By raising awareness of the barriers, physicians can enhance their own self-awareness to keenly be attuned to these challenges as patients cross their clinic threshold for medical care.

Additional resources link: www.cdc.gov/cancer/colorectal/

References

1. Klabunde CN et al. Trends in colorectal cancer test use among vulnerable populations in the United States. Cancer Epidemiol Biomarkers Prev. 2011 Aug;20(8):1611-21.

2. Parikh-Patel A et al. Colorectal cancer stage at diagnosis by socioeconomic and urban/rural status in California, 1988-2000. Cancer. 2006 Sep;107(5 Suppl):1189-95.

3. Promotion OoDPaH. Healthy People 2020. Cancer. Volume 2017.

4. Centers for Disease Control and Prevention. Cancer screening – United States, 2010. MMWR Morb Mortal Wkly Rep. 2012 Jan 27;61(3):41-5.

5. Doubeni CA et al. Racial and ethnic trends of colorectal cancer screening among Medicare enrollees. Am J Prev Med. 2010 Feb;38(2):184-91.

6. Kupfer SS et al. Reducing colorectal cancer risk among African Americans. Gastroenterology. 2015 Nov;149(6):1302-4.

7. Espey DK et al. Annual report to the nation on the status of cancer, 1975-2004, featuring cancer in American Indians and Alaska Natives. Cancer. 2007 Nov;110(10):2119-52.

8. Day LW et al. Screening prevalence and incidence of colorectal cancer among American Indian/Alaskan natives in the Indian Health Service. Dig Dis Sci. 2011 Jul;56(7):2104-13.

9. Gupta S et al. Challenges and possible solutions to colorectal cancer screening for the underserved. J Natl Cancer Inst. 2014 Apr;106(4):dju032.

10. Steele CB et al. Colorectal cancer incidence and screening – United States, 2008 and 2010. MMWR Suppl. 2013 Nov 22;62(3):53-60.

11. Boehmer U et al. Cancer survivorship and sexual orientation. Cancer 2011 Aug 15;117(16):3796-804.

12. Austin SB, Pazaris MJ, Wei EK, et al. Application of the Rosner-Wei risk-prediction model to estimate sexual orientation patterns in colon cancer risk in a prospective cohort of US women. Cancer Causes Control. 2014 Aug;25(8):999-1006.

13. Heslin KC et al. Sexual orientation and testing for prostate and colorectal cancers among men in California. Med Care. 2008 Dec;46(12):1240-8.

14. McElroy JA et al. Advancing Health Care for Lesbian, Gay, Bisexual, and Transgender Patients in Missouri. Mo Med. 2015 Jul-Aug;112(4):262-5.

15. Greiner KA et al. Knowledge and perceptions of colorectal cancer screening among urban African Americans. J Gen Intern Med. 2005 Nov;20(11):977-83.

16. Green PM, Kelly BA. Colorectal cancer knowledge, perceptions, and behaviors in African Americans. Cancer Nurs. 2004 May-Jun;27(3):206-15; quiz 216-7.

17. Berkowitz Z et al. Beliefs, risk perceptions, and gaps in knowledge as barriers to colorectal cancer screening in older adults. J Am Geriatr Soc. 2008 Feb;56(2):307-14.

18. Dolan NC et al. Colorectal cancer screening knowledge, attitudes, and beliefs among veterans: Does literacy make a difference? J Clin Oncol. 2004 Jul;22(13):2617-22.

19. Peterson NB et al. The influence of health literacy on colorectal cancer screening knowledge, beliefs and behavior. J Natl Med Assoc. 2007 Oct;99(10):1105-12.

20. Haddock MG et al. Intraoperative irradiation for locally recurrent colorectal cancer in previously irradiated patients. Int J Radiat Oncol Biol Phys. 2001 Apr 1;49(5):1267-74.

21. Jones RM et al. Patient-reported barriers to colorectal cancer screening: a mixed-methods analysis. Am J Prev Med. 2010 May;38(5):508-16.

22. Basch CH et al. Screening colonoscopy bowel preparation: experience in an urban minority population. Therap Adv Gastroenterol. 2013 Nov;6(6):442-6.

23. Davis JL et al. Sociodemographic differences in fears and mistrust contributing to unwillingness to participate in cancer screenings. J Health Care Poor Underserved. 2012 Nov;23(4 Suppl):67-76.

24. Robinson CM et al. Barriers to colorectal cancer screening among publicly insured urban women: no knowledge of tests and no clinician recommendation. J Natl Med Assoc. 2011 Aug;103(8):746-53.

25. Goldman RE et al. Perspectives of colorectal cancer risk and screening among Dominicans and Puerto Ricans: Stigma and misperceptions. Qual Health Res. 2009 Nov;19(11):1559-68.

26. Laiyemo AO et al. Race and colorectal cancer disparities: Health-care utilization vs different cancer susceptibilities. J Natl Cancer Inst. 2010 Apr 21;102(8):538-46.

27. White A et al. Racial disparities and treatment trends in a large cohort of elderly African Americans and Caucasians with colorectal cancer, 1991 to 2002. Cancer. 2008 Dec 15;113(12):3400-9.

28. Doubeni CA et al. Neighborhood socioeconomic status and use of colonoscopy in an insured population – A retrospective cohort study. PLoS One. 2012;7(5):e36392.

29. Tammana VS, Laiyemo AO. Colorectal cancer disparities: Issues, controversies and solutions. World J Gastroenterol. 2014 Jan 28;20(4):869-76.

30. Carethers JM. Screening for colorectal cancer in African Americans: determinants and rationale for an earlier age to commence screening. Dig Dis Sci. 2015 Mar;60(3):711-21.

31. Miranda-Diaz C et al. Barriers for Compliance to Breast, Colorectal, and Cervical Screening Cancer Tests among Hispanic Patients. Int J Environ Res Public Health. 2015 Dec 22;13(1):ijerph13010021.

32. Sewali B et al. Understanding cancer screening service utilization by Somali men in Minnesota. J Immigr Minor Health. 2015 Jun;17(3):773-80.

33. Walsh JM et al. Barriers to colorectal cancer screening in Latino and Vietnamese Americans. Compared with non-Latino white Americans. J Gen Intern Med. 2004 Feb;19(2):156-66.

34. Perez-Stable EJ et al. Self-reported use of cancer screening tests among Latinos and Anglos in a prepaid health plan. Arch Intern Med. 1994 May 23;154(10):1073-81.

35. Shariff-Marco S et al. Racial/ethnic differences in self-reported racism and its association with cancer-related health behaviors. Am J Public Health. 2010 Feb;100(2):364-74.

36. Powe BD et al. Comparing knowledge of colorectal and prostate cancer among African American and Hispanic men. Cancer Nurs. 2009 Sep-Oct;32(5):412-7.

37. Jun J, Oh KM. Asian and Hispanic Americans’ cancer fatalism and colon cancer screening. Am J Health Behav. 2013 Mar;37(2):145-54.

38. Hacker K et al. The impact of Immigration and Customs Enforcement on immigrant health: Perceptions of immigrants in Everett, Massachusetts, USA. Soc Sci Med. 2011 Aug;73(4):586-94.

39. Firger J. Rescinding DACA could spur a public health crisis, from lost services to higher rates of depression, substance abuse. Newsweek.

40. May FP et al. Racial minorities are more likely than whites to report lack of provider recommendation for colon cancer screening. Am J Gastroenterol. 2015 Oct;110(10):1388-94.

41. Levy BT et al. Why hasn’t this patient been screened for colon cancer? An Iowa Research Network study. J Am Board Fam Med. 2007 Sep-Oct;20(5):458-68.

42. Rosenblatt RA. A view from the periphery – health care in rural America. N Engl J Med. 2004 Sep 9;351(11):1049-51.

43. Young WF et al. Predictors of colorectal screening in rural Colorado: testing to prevent colon cancer in the high plains research network. J Rural Health. 2007 Summer;23(3):238-45.

44. Kates J et al. Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals in the U.S. In: Foundation KF, ed. Disparities Policy Issue Brief. Volume 2017; Aug 30, 2017.

45. Katz ML et al. Improving colorectal cancer screening by using community volunteers: results of the Carolinas cancer education and screening (CARES) project. Cancer. 2007 Oct 1;110(7):1602-10.

46. Jean-Jacques M et al. Program to improve colorectal cancer screening in a low-income, racially diverse population: A randomized controlled trial. Ann Fam Med. 2012 Sep-Oct;10(5):412-7.

47. Reuland DS et al. Effect of combined patient decision aid and patient navigation vs usual care for colorectal cancer screening in a vulnerable patient population: A randomized clinical trial. JAMA Intern Med. 2017 Jul 1;177(7):967-74.

48. Percac-Lima S et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med. 2009 Feb;24(2):211-7.

49. Nash D et al. Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting. J Urban Health. 2006 Mar;83(2):231-43.

50. Lebwohl B et al. Effect of a patient navigator program on the volume and quality of colonoscopy. J Clin Gastroenterol. 2011 May-Jun;45(5):e47-53.

51. Khankari K et al. Improving colorectal cancer screening among the medically underserved: A pilot study within a federally qualified health center. J Gen Intern Med. 2007 Oct;22(10):1410-4.

52. Wang JH et al. Recruiting Chinese Americans into cancer screening intervention trials: Strategies and outcomes. Clin Trials. 2014 Apr;11(2):167-77.

53. Katz ML et al. Patient activation increases colorectal cancer screening rates: a randomized trial among low-income minority patients. Cancer Epidemiol Biomarkers Prev. 2012 Jan;21(1):45-52.

54. Ford ME et al. Enhancing adherence among older African American men enrolled in a longitudinal cancer screening trial. Gerontologist. 2006 Aug;46(4):545-50.

55. Christie J et al. A randomized controlled trial using patient navigation to increase colonoscopy screening among low-income minorities. J Natl Med Assoc. 2008 Mar;100(3):278-84.

56. Philip EJ et al. Evaluating the impact of an educational intervention to increase CRC screening rates in the African American community: A preliminary study. Cancer Causes Control. 2010 Oct;21(10):1685-91.

57. Greiner KA et al. Implementation intentions and colorectal screening: A randomized trial in safety-net clinics. Am J Prev Med. 2014 Dec;47(6):703-14.

58. Horne HN et al. Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults. Cancer Causes Control. 2015 Feb;26(2):239-46.

59. Grubbs SS et al. Eliminating racial disparities in colorectal cancer in the real world: It took a village. J Clin Oncol. 2013 Jun 1;31(16):1928-30.

60. Jung MY et al. The Chinese and Korean American immigrant experience: a mixed-methods examination of facilitators and barriers of colorectal cancer screening. Ethn Health. 2017 Feb 25:1-20.

61. Viruell-Fuentes EA et al. More than culture: structural racism, intersectionality theory, and immigrant health. Soc Sci Med. 2012 Dec;75(12):2099-106.

Dr. Oduyebo is a third-year fellow at the Mayo Clinic, Rochester, Minn.; Dr. Malespin is an assistant professor in the department of medicine and the medical director of hepatology at the University of Florida Health, Jacksonville; Dr. Mendoza Ladd is an assistant professor of medicine at Texas Tech University, El Paso; Dr. Day is an associate professor of medicine at the University of California, San Francisco; Dr. Charabaty is an associate professor of medicine and the director of the IBD Center in the division of gastroenterology at Medstar-Georgetown University Center, Washington; Dr. Chen is an associate professor of medicine, the director of patient safety and quality, and the director of the small-bowel endoscopy program in division of gastroenterology at Washington University, St. Louis; Dr. Carr is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia; Dr. Quezada is an assistant dean for admissions, an assistant dean for academic and multicultural affairs, and an assistant professor of medicine in the division of gastroenterology and hepatology at the University of Maryland, Baltimore; and Dr. Lamousé-Smith is a director of translational medicine, immunology, and early development at Janssen Pharmaceuticals Research and Development, Spring House, Penn.

Editor's Note: 

As we all strive to improve the rate of colorectal cancer screening, it is important to acknowledge that barriers exist that prevent screening uptake.

Importantly, these barriers often vary between specific population subsets. In this month’s In Focus article, brought to you by The New Gastroenterologist, the members of the AGA Institute Diversity Committee provide an enlightening overview of the barriers affecting underserved populations as well as strategies that can be employed to overcome these impediments. Better understanding of patient-specific barriers will, I hope, allow us to more effectively redress them and ultimately increase colorectal cancer screening rates in all populations.

Bryson W. Katona, MD, PhD
Editor in Chief, The New Gastroenterologist

Despite the positive public health effects of colorectal cancer (CRC) screening, there remains differential uptake of CRC screening in the United States. Minority populations born in the United States and immigrant populations are among those with the lowest rates of CRC screening, and both socioeconomic status and ethnicity are strongly associated with stage of CRC at diagnosis.^1,2 Thus, recognizing the economic, social, and cultural factors that result in low rates of CRC screening in underserved populations is important in order to devise targeted interventions to increase CRC uptake and reduce morbidity and mortality in these populations.

Vidyard Video

What are the facts and figures?

The overall rate of screening colonoscopies has increased in all ethnic groups in the past 10 years but still falls below the goal of 71% established by the Healthy People project (www.healthypeople.gov) for the year 2020.³ According to the Centers for Disease Control and Prevention ethnicity-specific data for U.S.-born populations, 60% of whites, 55% of African Americans (AA), 50% of American Indian/Alaskan natives (AI/AN), 46% of Latino Americans, and 47% of Asians undergo CRC screening (Figure 1A).⁴ While CRC incidence in non-Hispanic whites age 50 years and older has dropped by 32% since 2000 because of screening, this trend has not been observed in AAs.^5,6

The incidence of CRC in AAs is estimated at 49/10,000, one of the highest amongst U.S. populations and is the second and third most common cancer in AA women and men, respectively (Figure 1B).

Similar to AAs, AI/AN patients present with more advanced CRC disease and at younger ages and have lower survival rates, compared with other racial groups, a trend that has not changed in the last decade.⁷ CRC screening data in this population vary according to sex, geographic location, and health care utilization, with as few as 4.0% of asymptomatic, average-risk AI/ANs who receive medical care in the Indian Health Services being screened for CRC.⁸

The low rate of CRC screening among Latinos also poses a significant obstacle to the Healthy People project since it is expected that by 2060 Latinos will constitute 30% of the U.S. population. Therefore, strategies to improve CRC screening in this population are needed to continue the gains made in overall CRC mortality rates.

The percentage of immigrants in the U.S. population increased from 4.7% in 1970 to 13.5% in 2015. Immigrants, regardless of their ethnicity, represent a very vulnerable population, and CRC screening data in this population are not as robust as for U.S.-born groups. In general, immigrants have substantially lower CRC screening rates, compared with U.S.-born populations (21% vs. 60%),⁹ and it is suspected that additional, significant barriers to CRC screening and care exist for undocumented immigrants.

Another often overlooked group, are individuals with physical or cognitive disabilities. In this group, screening rates range from 49% to 65%.¹⁰

Finally, while information is available for many health care conditions and disparities faced by various ethnic groups, there are few CRC screening data for the LGBTQ community. Perhaps amplifying this problem is the existence of conflicting data in this population, with some studies suggesting there is no difference in CRC risk across groups in the LGBTQ community and others suggesting an increased risk.^11,12 Notably, sexual orientation has been identified as a positive predictor of CRC screening in gay and bisexual men – CRC screening rates are higher in these groups, compared with heterosexual men.¹³ In contrast, no such difference has been found between homosexual and heterosexual women.¹⁴

What are the barriers?

Several common themes contribute to disparities in CRC screening among minority groups, including psychosocial/cultural, socioeconomic, provider-specific, and insurance-related factors. Some patient-related barriers include issues of illiteracy, having poor health literacy or English proficiency, having only grade school education,^15,16 cultural misconceptions, transportation issues, difficulties affording copayments or deductibles, and a lack of follow-up for scheduled appointments and exams.^17-20 Poor health literacy has a profound effect on exam perceptions, fear of test results, and compliance with scheduling tests and bowel preparation instructions^21-25; it also affects one’s understanding of the importance of CRC screening, the recommended screening age, and the available choice of screening tests.

Even when some apparent barriers are mitigated, disparities in CRC screening remain. For example, even among the insured and among Medicare beneficiaries, screening rates and adequate follow-up rates after abnormal findings remain lower among AAs and those of low socioeconomic status than they are among whites.^26-28 At least part of this paradox results from the presence of unmeasured cultural/belief systems that affect CRC screening uptake. Some of these factors include fear and/or denial of CRC diagnoses, mistrust of the health care system, and reluctance to undergo medical treatment and surgery.^16,29 AAs are also less likely to be aware of a family history of CRC and to discuss personal and/or family history of CRC or polyps, which can thereby hinder the identification of high-risk individuals who would benefit from early screening.^15,30

The deeply rooted sense of fatalism also plays a crucial role and has been cited for many minority and immigrant populations. Fatalism leads patients to view a diagnosis of cancer as a matter of “fate” or “God’s will,” and therefore, it is to be endured.^23,31 Similarly, in a qualitative study of 44 Somali men living in St. Paul and Minneapolis, believing cancer was more common in whites, believing they were protected from cancer by God, fearing a cancer diagnosis, and fearing ostracism from their community were reported as barriers to cancer screening.³²

Perceptions about CRC screening methods in Latino populations also have a tremendous influence and can include fear, stigma of sexual prejudice, embarrassment of being exposed during the exam, worries about humiliation in a male sense of masculinity, a lack of trust in the medical professionals, a sense of being a “guinea pig” for physicians, concerns about health care racism, and expectations of pain.^33-37 Studies have reported that immigrants are afraid to seek health care because of the increasingly hostile environment associated with immigration enforcement.³⁸ In addition, the impending dissolution of the Deferred Action for Childhood Arrivals act is likely to augment the barriers to care for Latino groups.³⁹

In addition, provider-specific barriers to care also exist. Racial and ethnic minorities are less likely than whites to receive recommendations for screening by their physician. In fact, this factor alone has been demonstrated to be the main reason for lack of screening among AAs in a Californian cohort.⁴⁰ In addition, patients from rural areas or those from AI/AN communities are at especially increased risk for lack of access to care because of a scarcity of providers along with patient perceptions regarding their primary care provider’s ability to connect them to subspecialists.^41-43 Other cited examples include misconceptions about and poor treatment of the LGBTQ population by health care providers/systems.⁴⁴

How can we intervene successfully?

Characterization of barriers is important because it promotes the development of targeted interventions. Intervention models include community engagement programs, incorporation of fecal occult testing, and patient navigator programs.^45-47 In response to the alarming disparity in CRC screening rates in Latino communities, several interventions have been set in motion in different clinical scenarios, which include patient navigation and a focus on patient education.

Randomized trials have shown that outreach efforts and patient navigation increase CRC screening rates in AAs.^48,54,55 Studies evaluating the effects of print-based educational materials on improving screening showed improvement in screening rates, decreases in cancer-related fatalistic attitudes, and patients had a better understanding of the benefits of screening as compared with the cost associated with screening and the cost of advanced disease.⁵⁶ Similarly, the use of touch-screen computers that tailor informational messages to decisional stage and screening barriers increased participation in CRC screening.⁵⁷ Including patient navigators along with printed education material was even more effective at increasing the proportion of patients getting colonoscopy screening than providing printed material alone, with more-intensive navigation needed for individuals with low literacy.⁵⁸ Grubbs et al.reported the success of their patient navigation program, which included wider comprehensive screening and coverage for colonoscopy screening.⁵⁹ In AAs, they estimated an annual reduction of CRC incidence and mortality of 4,200 and 2,700 patients, respectively.

Among immigrants, there is an increased likelihood of CRC screening in those immigrants with a higher number of primary care visits.⁶⁰ The intersection of culture, race, socioeconomic status, housing enclaves, limited English proficiency, low health literacy, and immigration policy all play a role in immigrant health and access to health care.⁶¹

Courtesy Aline Charabaty

Therefore, different strategies may be needed for each immigrant group to improve CRC screening. For this group of patients, efforts aimed at mitigating the adverse effects of national immigration policies on immigrant populations may have the additional consequence of improving health care access and CRC screening for these patients.

Data gaps still exist in our understanding of patient perceptions, perspectives, and barriers that present opportunities for further study to develop long-lasting interventions that will improve health care of underserved populations. By raising awareness of the barriers, physicians can enhance their own self-awareness to keenly be attuned to these challenges as patients cross their clinic threshold for medical care.

Additional resources link: www.cdc.gov/cancer/colorectal/

References

1. Klabunde CN et al. Trends in colorectal cancer test use among vulnerable populations in the United States. Cancer Epidemiol Biomarkers Prev. 2011 Aug;20(8):1611-21.

2. Parikh-Patel A et al. Colorectal cancer stage at diagnosis by socioeconomic and urban/rural status in California, 1988-2000. Cancer. 2006 Sep;107(5 Suppl):1189-95.

3. Promotion OoDPaH. Healthy People 2020. Cancer. Volume 2017.

4. Centers for Disease Control and Prevention. Cancer screening – United States, 2010. MMWR Morb Mortal Wkly Rep. 2012 Jan 27;61(3):41-5.

5. Doubeni CA et al. Racial and ethnic trends of colorectal cancer screening among Medicare enrollees. Am J Prev Med. 2010 Feb;38(2):184-91.

6. Kupfer SS et al. Reducing colorectal cancer risk among African Americans. Gastroenterology. 2015 Nov;149(6):1302-4.

7. Espey DK et al. Annual report to the nation on the status of cancer, 1975-2004, featuring cancer in American Indians and Alaska Natives. Cancer. 2007 Nov;110(10):2119-52.

8. Day LW et al. Screening prevalence and incidence of colorectal cancer among American Indian/Alaskan natives in the Indian Health Service. Dig Dis Sci. 2011 Jul;56(7):2104-13.

9. Gupta S et al. Challenges and possible solutions to colorectal cancer screening for the underserved. J Natl Cancer Inst. 2014 Apr;106(4):dju032.

10. Steele CB et al. Colorectal cancer incidence and screening – United States, 2008 and 2010. MMWR Suppl. 2013 Nov 22;62(3):53-60.

11. Boehmer U et al. Cancer survivorship and sexual orientation. Cancer 2011 Aug 15;117(16):3796-804.

12. Austin SB, Pazaris MJ, Wei EK, et al. Application of the Rosner-Wei risk-prediction model to estimate sexual orientation patterns in colon cancer risk in a prospective cohort of US women. Cancer Causes Control. 2014 Aug;25(8):999-1006.

13. Heslin KC et al. Sexual orientation and testing for prostate and colorectal cancers among men in California. Med Care. 2008 Dec;46(12):1240-8.

14. McElroy JA et al. Advancing Health Care for Lesbian, Gay, Bisexual, and Transgender Patients in Missouri. Mo Med. 2015 Jul-Aug;112(4):262-5.

15. Greiner KA et al. Knowledge and perceptions of colorectal cancer screening among urban African Americans. J Gen Intern Med. 2005 Nov;20(11):977-83.

16. Green PM, Kelly BA. Colorectal cancer knowledge, perceptions, and behaviors in African Americans. Cancer Nurs. 2004 May-Jun;27(3):206-15; quiz 216-7.

17. Berkowitz Z et al. Beliefs, risk perceptions, and gaps in knowledge as barriers to colorectal cancer screening in older adults. J Am Geriatr Soc. 2008 Feb;56(2):307-14.

18. Dolan NC et al. Colorectal cancer screening knowledge, attitudes, and beliefs among veterans: Does literacy make a difference? J Clin Oncol. 2004 Jul;22(13):2617-22.

19. Peterson NB et al. The influence of health literacy on colorectal cancer screening knowledge, beliefs and behavior. J Natl Med Assoc. 2007 Oct;99(10):1105-12.

20. Haddock MG et al. Intraoperative irradiation for locally recurrent colorectal cancer in previously irradiated patients. Int J Radiat Oncol Biol Phys. 2001 Apr 1;49(5):1267-74.

21. Jones RM et al. Patient-reported barriers to colorectal cancer screening: a mixed-methods analysis. Am J Prev Med. 2010 May;38(5):508-16.

22. Basch CH et al. Screening colonoscopy bowel preparation: experience in an urban minority population. Therap Adv Gastroenterol. 2013 Nov;6(6):442-6.

23. Davis JL et al. Sociodemographic differences in fears and mistrust contributing to unwillingness to participate in cancer screenings. J Health Care Poor Underserved. 2012 Nov;23(4 Suppl):67-76.

24. Robinson CM et al. Barriers to colorectal cancer screening among publicly insured urban women: no knowledge of tests and no clinician recommendation. J Natl Med Assoc. 2011 Aug;103(8):746-53.

25. Goldman RE et al. Perspectives of colorectal cancer risk and screening among Dominicans and Puerto Ricans: Stigma and misperceptions. Qual Health Res. 2009 Nov;19(11):1559-68.

26. Laiyemo AO et al. Race and colorectal cancer disparities: Health-care utilization vs different cancer susceptibilities. J Natl Cancer Inst. 2010 Apr 21;102(8):538-46.

27. White A et al. Racial disparities and treatment trends in a large cohort of elderly African Americans and Caucasians with colorectal cancer, 1991 to 2002. Cancer. 2008 Dec 15;113(12):3400-9.

28. Doubeni CA et al. Neighborhood socioeconomic status and use of colonoscopy in an insured population – A retrospective cohort study. PLoS One. 2012;7(5):e36392.

29. Tammana VS, Laiyemo AO. Colorectal cancer disparities: Issues, controversies and solutions. World J Gastroenterol. 2014 Jan 28;20(4):869-76.

30. Carethers JM. Screening for colorectal cancer in African Americans: determinants and rationale for an earlier age to commence screening. Dig Dis Sci. 2015 Mar;60(3):711-21.

31. Miranda-Diaz C et al. Barriers for Compliance to Breast, Colorectal, and Cervical Screening Cancer Tests among Hispanic Patients. Int J Environ Res Public Health. 2015 Dec 22;13(1):ijerph13010021.

32. Sewali B et al. Understanding cancer screening service utilization by Somali men in Minnesota. J Immigr Minor Health. 2015 Jun;17(3):773-80.

33. Walsh JM et al. Barriers to colorectal cancer screening in Latino and Vietnamese Americans. Compared with non-Latino white Americans. J Gen Intern Med. 2004 Feb;19(2):156-66.

34. Perez-Stable EJ et al. Self-reported use of cancer screening tests among Latinos and Anglos in a prepaid health plan. Arch Intern Med. 1994 May 23;154(10):1073-81.

35. Shariff-Marco S et al. Racial/ethnic differences in self-reported racism and its association with cancer-related health behaviors. Am J Public Health. 2010 Feb;100(2):364-74.

36. Powe BD et al. Comparing knowledge of colorectal and prostate cancer among African American and Hispanic men. Cancer Nurs. 2009 Sep-Oct;32(5):412-7.

37. Jun J, Oh KM. Asian and Hispanic Americans’ cancer fatalism and colon cancer screening. Am J Health Behav. 2013 Mar;37(2):145-54.

38. Hacker K et al. The impact of Immigration and Customs Enforcement on immigrant health: Perceptions of immigrants in Everett, Massachusetts, USA. Soc Sci Med. 2011 Aug;73(4):586-94.

39. Firger J. Rescinding DACA could spur a public health crisis, from lost services to higher rates of depression, substance abuse. Newsweek.

40. May FP et al. Racial minorities are more likely than whites to report lack of provider recommendation for colon cancer screening. Am J Gastroenterol. 2015 Oct;110(10):1388-94.

41. Levy BT et al. Why hasn’t this patient been screened for colon cancer? An Iowa Research Network study. J Am Board Fam Med. 2007 Sep-Oct;20(5):458-68.

42. Rosenblatt RA. A view from the periphery – health care in rural America. N Engl J Med. 2004 Sep 9;351(11):1049-51.

43. Young WF et al. Predictors of colorectal screening in rural Colorado: testing to prevent colon cancer in the high plains research network. J Rural Health. 2007 Summer;23(3):238-45.

44. Kates J et al. Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals in the U.S. In: Foundation KF, ed. Disparities Policy Issue Brief. Volume 2017; Aug 30, 2017.

45. Katz ML et al. Improving colorectal cancer screening by using community volunteers: results of the Carolinas cancer education and screening (CARES) project. Cancer. 2007 Oct 1;110(7):1602-10.

46. Jean-Jacques M et al. Program to improve colorectal cancer screening in a low-income, racially diverse population: A randomized controlled trial. Ann Fam Med. 2012 Sep-Oct;10(5):412-7.

47. Reuland DS et al. Effect of combined patient decision aid and patient navigation vs usual care for colorectal cancer screening in a vulnerable patient population: A randomized clinical trial. JAMA Intern Med. 2017 Jul 1;177(7):967-74.

48. Percac-Lima S et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med. 2009 Feb;24(2):211-7.

49. Nash D et al. Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting. J Urban Health. 2006 Mar;83(2):231-43.

50. Lebwohl B et al. Effect of a patient navigator program on the volume and quality of colonoscopy. J Clin Gastroenterol. 2011 May-Jun;45(5):e47-53.

51. Khankari K et al. Improving colorectal cancer screening among the medically underserved: A pilot study within a federally qualified health center. J Gen Intern Med. 2007 Oct;22(10):1410-4.

52. Wang JH et al. Recruiting Chinese Americans into cancer screening intervention trials: Strategies and outcomes. Clin Trials. 2014 Apr;11(2):167-77.

53. Katz ML et al. Patient activation increases colorectal cancer screening rates: a randomized trial among low-income minority patients. Cancer Epidemiol Biomarkers Prev. 2012 Jan;21(1):45-52.

54. Ford ME et al. Enhancing adherence among older African American men enrolled in a longitudinal cancer screening trial. Gerontologist. 2006 Aug;46(4):545-50.

55. Christie J et al. A randomized controlled trial using patient navigation to increase colonoscopy screening among low-income minorities. J Natl Med Assoc. 2008 Mar;100(3):278-84.

56. Philip EJ et al. Evaluating the impact of an educational intervention to increase CRC screening rates in the African American community: A preliminary study. Cancer Causes Control. 2010 Oct;21(10):1685-91.

57. Greiner KA et al. Implementation intentions and colorectal screening: A randomized trial in safety-net clinics. Am J Prev Med. 2014 Dec;47(6):703-14.

58. Horne HN et al. Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults. Cancer Causes Control. 2015 Feb;26(2):239-46.

59. Grubbs SS et al. Eliminating racial disparities in colorectal cancer in the real world: It took a village. J Clin Oncol. 2013 Jun 1;31(16):1928-30.

60. Jung MY et al. The Chinese and Korean American immigrant experience: a mixed-methods examination of facilitators and barriers of colorectal cancer screening. Ethn Health. 2017 Feb 25:1-20.

61. Viruell-Fuentes EA et al. More than culture: structural racism, intersectionality theory, and immigrant health. Soc Sci Med. 2012 Dec;75(12):2099-106.

Dr. Oduyebo is a third-year fellow at the Mayo Clinic, Rochester, Minn.; Dr. Malespin is an assistant professor in the department of medicine and the medical director of hepatology at the University of Florida Health, Jacksonville; Dr. Mendoza Ladd is an assistant professor of medicine at Texas Tech University, El Paso; Dr. Day is an associate professor of medicine at the University of California, San Francisco; Dr. Charabaty is an associate professor of medicine and the director of the IBD Center in the division of gastroenterology at Medstar-Georgetown University Center, Washington; Dr. Chen is an associate professor of medicine, the director of patient safety and quality, and the director of the small-bowel endoscopy program in division of gastroenterology at Washington University, St. Louis; Dr. Carr is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia; Dr. Quezada is an assistant dean for admissions, an assistant dean for academic and multicultural affairs, and an assistant professor of medicine in the division of gastroenterology and hepatology at the University of Maryland, Baltimore; and Dr. Lamousé-Smith is a director of translational medicine, immunology, and early development at Janssen Pharmaceuticals Research and Development, Spring House, Penn.

Editor's Note: 

As we all strive to improve the rate of colorectal cancer screening, it is important to acknowledge that barriers exist that prevent screening uptake.

Importantly, these barriers often vary between specific population subsets. In this month’s In Focus article, brought to you by The New Gastroenterologist, the members of the AGA Institute Diversity Committee provide an enlightening overview of the barriers affecting underserved populations as well as strategies that can be employed to overcome these impediments. Better understanding of patient-specific barriers will, I hope, allow us to more effectively redress them and ultimately increase colorectal cancer screening rates in all populations.

Bryson W. Katona, MD, PhD
Editor in Chief, The New Gastroenterologist

Despite the positive public health effects of colorectal cancer (CRC) screening, there remains differential uptake of CRC screening in the United States. Minority populations born in the United States and immigrant populations are among those with the lowest rates of CRC screening, and both socioeconomic status and ethnicity are strongly associated with stage of CRC at diagnosis.^1,2 Thus, recognizing the economic, social, and cultural factors that result in low rates of CRC screening in underserved populations is important in order to devise targeted interventions to increase CRC uptake and reduce morbidity and mortality in these populations.

Vidyard Video

What are the facts and figures?

The overall rate of screening colonoscopies has increased in all ethnic groups in the past 10 years but still falls below the goal of 71% established by the Healthy People project (www.healthypeople.gov) for the year 2020.³ According to the Centers for Disease Control and Prevention ethnicity-specific data for U.S.-born populations, 60% of whites, 55% of African Americans (AA), 50% of American Indian/Alaskan natives (AI/AN), 46% of Latino Americans, and 47% of Asians undergo CRC screening (Figure 1A).⁴ While CRC incidence in non-Hispanic whites age 50 years and older has dropped by 32% since 2000 because of screening, this trend has not been observed in AAs.^5,6

The incidence of CRC in AAs is estimated at 49/10,000, one of the highest amongst U.S. populations and is the second and third most common cancer in AA women and men, respectively (Figure 1B).

Similar to AAs, AI/AN patients present with more advanced CRC disease and at younger ages and have lower survival rates, compared with other racial groups, a trend that has not changed in the last decade.⁷ CRC screening data in this population vary according to sex, geographic location, and health care utilization, with as few as 4.0% of asymptomatic, average-risk AI/ANs who receive medical care in the Indian Health Services being screened for CRC.⁸

The low rate of CRC screening among Latinos also poses a significant obstacle to the Healthy People project since it is expected that by 2060 Latinos will constitute 30% of the U.S. population. Therefore, strategies to improve CRC screening in this population are needed to continue the gains made in overall CRC mortality rates.

The percentage of immigrants in the U.S. population increased from 4.7% in 1970 to 13.5% in 2015. Immigrants, regardless of their ethnicity, represent a very vulnerable population, and CRC screening data in this population are not as robust as for U.S.-born groups. In general, immigrants have substantially lower CRC screening rates, compared with U.S.-born populations (21% vs. 60%),⁹ and it is suspected that additional, significant barriers to CRC screening and care exist for undocumented immigrants.

Another often overlooked group, are individuals with physical or cognitive disabilities. In this group, screening rates range from 49% to 65%.¹⁰

Finally, while information is available for many health care conditions and disparities faced by various ethnic groups, there are few CRC screening data for the LGBTQ community. Perhaps amplifying this problem is the existence of conflicting data in this population, with some studies suggesting there is no difference in CRC risk across groups in the LGBTQ community and others suggesting an increased risk.^11,12 Notably, sexual orientation has been identified as a positive predictor of CRC screening in gay and bisexual men – CRC screening rates are higher in these groups, compared with heterosexual men.¹³ In contrast, no such difference has been found between homosexual and heterosexual women.¹⁴

What are the barriers?

Several common themes contribute to disparities in CRC screening among minority groups, including psychosocial/cultural, socioeconomic, provider-specific, and insurance-related factors. Some patient-related barriers include issues of illiteracy, having poor health literacy or English proficiency, having only grade school education,^15,16 cultural misconceptions, transportation issues, difficulties affording copayments or deductibles, and a lack of follow-up for scheduled appointments and exams.^17-20 Poor health literacy has a profound effect on exam perceptions, fear of test results, and compliance with scheduling tests and bowel preparation instructions^21-25; it also affects one’s understanding of the importance of CRC screening, the recommended screening age, and the available choice of screening tests.

Even when some apparent barriers are mitigated, disparities in CRC screening remain. For example, even among the insured and among Medicare beneficiaries, screening rates and adequate follow-up rates after abnormal findings remain lower among AAs and those of low socioeconomic status than they are among whites.^26-28 At least part of this paradox results from the presence of unmeasured cultural/belief systems that affect CRC screening uptake. Some of these factors include fear and/or denial of CRC diagnoses, mistrust of the health care system, and reluctance to undergo medical treatment and surgery.^16,29 AAs are also less likely to be aware of a family history of CRC and to discuss personal and/or family history of CRC or polyps, which can thereby hinder the identification of high-risk individuals who would benefit from early screening.^15,30

The deeply rooted sense of fatalism also plays a crucial role and has been cited for many minority and immigrant populations. Fatalism leads patients to view a diagnosis of cancer as a matter of “fate” or “God’s will,” and therefore, it is to be endured.^23,31 Similarly, in a qualitative study of 44 Somali men living in St. Paul and Minneapolis, believing cancer was more common in whites, believing they were protected from cancer by God, fearing a cancer diagnosis, and fearing ostracism from their community were reported as barriers to cancer screening.³²

Perceptions about CRC screening methods in Latino populations also have a tremendous influence and can include fear, stigma of sexual prejudice, embarrassment of being exposed during the exam, worries about humiliation in a male sense of masculinity, a lack of trust in the medical professionals, a sense of being a “guinea pig” for physicians, concerns about health care racism, and expectations of pain.^33-37 Studies have reported that immigrants are afraid to seek health care because of the increasingly hostile environment associated with immigration enforcement.³⁸ In addition, the impending dissolution of the Deferred Action for Childhood Arrivals act is likely to augment the barriers to care for Latino groups.³⁹

In addition, provider-specific barriers to care also exist. Racial and ethnic minorities are less likely than whites to receive recommendations for screening by their physician. In fact, this factor alone has been demonstrated to be the main reason for lack of screening among AAs in a Californian cohort.⁴⁰ In addition, patients from rural areas or those from AI/AN communities are at especially increased risk for lack of access to care because of a scarcity of providers along with patient perceptions regarding their primary care provider’s ability to connect them to subspecialists.^41-43 Other cited examples include misconceptions about and poor treatment of the LGBTQ population by health care providers/systems.⁴⁴

How can we intervene successfully?

Characterization of barriers is important because it promotes the development of targeted interventions. Intervention models include community engagement programs, incorporation of fecal occult testing, and patient navigator programs.^45-47 In response to the alarming disparity in CRC screening rates in Latino communities, several interventions have been set in motion in different clinical scenarios, which include patient navigation and a focus on patient education.

Randomized trials have shown that outreach efforts and patient navigation increase CRC screening rates in AAs.^48,54,55 Studies evaluating the effects of print-based educational materials on improving screening showed improvement in screening rates, decreases in cancer-related fatalistic attitudes, and patients had a better understanding of the benefits of screening as compared with the cost associated with screening and the cost of advanced disease.⁵⁶ Similarly, the use of touch-screen computers that tailor informational messages to decisional stage and screening barriers increased participation in CRC screening.⁵⁷ Including patient navigators along with printed education material was even more effective at increasing the proportion of patients getting colonoscopy screening than providing printed material alone, with more-intensive navigation needed for individuals with low literacy.⁵⁸ Grubbs et al.reported the success of their patient navigation program, which included wider comprehensive screening and coverage for colonoscopy screening.⁵⁹ In AAs, they estimated an annual reduction of CRC incidence and mortality of 4,200 and 2,700 patients, respectively.

Among immigrants, there is an increased likelihood of CRC screening in those immigrants with a higher number of primary care visits.⁶⁰ The intersection of culture, race, socioeconomic status, housing enclaves, limited English proficiency, low health literacy, and immigration policy all play a role in immigrant health and access to health care.⁶¹

Courtesy Aline Charabaty

Therefore, different strategies may be needed for each immigrant group to improve CRC screening. For this group of patients, efforts aimed at mitigating the adverse effects of national immigration policies on immigrant populations may have the additional consequence of improving health care access and CRC screening for these patients.

Data gaps still exist in our understanding of patient perceptions, perspectives, and barriers that present opportunities for further study to develop long-lasting interventions that will improve health care of underserved populations. By raising awareness of the barriers, physicians can enhance their own self-awareness to keenly be attuned to these challenges as patients cross their clinic threshold for medical care.

Additional resources link: www.cdc.gov/cancer/colorectal/

References

1. Klabunde CN et al. Trends in colorectal cancer test use among vulnerable populations in the United States. Cancer Epidemiol Biomarkers Prev. 2011 Aug;20(8):1611-21.

2. Parikh-Patel A et al. Colorectal cancer stage at diagnosis by socioeconomic and urban/rural status in California, 1988-2000. Cancer. 2006 Sep;107(5 Suppl):1189-95.

3. Promotion OoDPaH. Healthy People 2020. Cancer. Volume 2017.

4. Centers for Disease Control and Prevention. Cancer screening – United States, 2010. MMWR Morb Mortal Wkly Rep. 2012 Jan 27;61(3):41-5.

5. Doubeni CA et al. Racial and ethnic trends of colorectal cancer screening among Medicare enrollees. Am J Prev Med. 2010 Feb;38(2):184-91.

6. Kupfer SS et al. Reducing colorectal cancer risk among African Americans. Gastroenterology. 2015 Nov;149(6):1302-4.

7. Espey DK et al. Annual report to the nation on the status of cancer, 1975-2004, featuring cancer in American Indians and Alaska Natives. Cancer. 2007 Nov;110(10):2119-52.

8. Day LW et al. Screening prevalence and incidence of colorectal cancer among American Indian/Alaskan natives in the Indian Health Service. Dig Dis Sci. 2011 Jul;56(7):2104-13.

9. Gupta S et al. Challenges and possible solutions to colorectal cancer screening for the underserved. J Natl Cancer Inst. 2014 Apr;106(4):dju032.

10. Steele CB et al. Colorectal cancer incidence and screening – United States, 2008 and 2010. MMWR Suppl. 2013 Nov 22;62(3):53-60.

11. Boehmer U et al. Cancer survivorship and sexual orientation. Cancer 2011 Aug 15;117(16):3796-804.

12. Austin SB, Pazaris MJ, Wei EK, et al. Application of the Rosner-Wei risk-prediction model to estimate sexual orientation patterns in colon cancer risk in a prospective cohort of US women. Cancer Causes Control. 2014 Aug;25(8):999-1006.

13. Heslin KC et al. Sexual orientation and testing for prostate and colorectal cancers among men in California. Med Care. 2008 Dec;46(12):1240-8.

14. McElroy JA et al. Advancing Health Care for Lesbian, Gay, Bisexual, and Transgender Patients in Missouri. Mo Med. 2015 Jul-Aug;112(4):262-5.

15. Greiner KA et al. Knowledge and perceptions of colorectal cancer screening among urban African Americans. J Gen Intern Med. 2005 Nov;20(11):977-83.

16. Green PM, Kelly BA. Colorectal cancer knowledge, perceptions, and behaviors in African Americans. Cancer Nurs. 2004 May-Jun;27(3):206-15; quiz 216-7.

17. Berkowitz Z et al. Beliefs, risk perceptions, and gaps in knowledge as barriers to colorectal cancer screening in older adults. J Am Geriatr Soc. 2008 Feb;56(2):307-14.

18. Dolan NC et al. Colorectal cancer screening knowledge, attitudes, and beliefs among veterans: Does literacy make a difference? J Clin Oncol. 2004 Jul;22(13):2617-22.

19. Peterson NB et al. The influence of health literacy on colorectal cancer screening knowledge, beliefs and behavior. J Natl Med Assoc. 2007 Oct;99(10):1105-12.

20. Haddock MG et al. Intraoperative irradiation for locally recurrent colorectal cancer in previously irradiated patients. Int J Radiat Oncol Biol Phys. 2001 Apr 1;49(5):1267-74.

21. Jones RM et al. Patient-reported barriers to colorectal cancer screening: a mixed-methods analysis. Am J Prev Med. 2010 May;38(5):508-16.

22. Basch CH et al. Screening colonoscopy bowel preparation: experience in an urban minority population. Therap Adv Gastroenterol. 2013 Nov;6(6):442-6.

23. Davis JL et al. Sociodemographic differences in fears and mistrust contributing to unwillingness to participate in cancer screenings. J Health Care Poor Underserved. 2012 Nov;23(4 Suppl):67-76.

24. Robinson CM et al. Barriers to colorectal cancer screening among publicly insured urban women: no knowledge of tests and no clinician recommendation. J Natl Med Assoc. 2011 Aug;103(8):746-53.

25. Goldman RE et al. Perspectives of colorectal cancer risk and screening among Dominicans and Puerto Ricans: Stigma and misperceptions. Qual Health Res. 2009 Nov;19(11):1559-68.

26. Laiyemo AO et al. Race and colorectal cancer disparities: Health-care utilization vs different cancer susceptibilities. J Natl Cancer Inst. 2010 Apr 21;102(8):538-46.

27. White A et al. Racial disparities and treatment trends in a large cohort of elderly African Americans and Caucasians with colorectal cancer, 1991 to 2002. Cancer. 2008 Dec 15;113(12):3400-9.

28. Doubeni CA et al. Neighborhood socioeconomic status and use of colonoscopy in an insured population – A retrospective cohort study. PLoS One. 2012;7(5):e36392.

29. Tammana VS, Laiyemo AO. Colorectal cancer disparities: Issues, controversies and solutions. World J Gastroenterol. 2014 Jan 28;20(4):869-76.

30. Carethers JM. Screening for colorectal cancer in African Americans: determinants and rationale for an earlier age to commence screening. Dig Dis Sci. 2015 Mar;60(3):711-21.

31. Miranda-Diaz C et al. Barriers for Compliance to Breast, Colorectal, and Cervical Screening Cancer Tests among Hispanic Patients. Int J Environ Res Public Health. 2015 Dec 22;13(1):ijerph13010021.

32. Sewali B et al. Understanding cancer screening service utilization by Somali men in Minnesota. J Immigr Minor Health. 2015 Jun;17(3):773-80.

33. Walsh JM et al. Barriers to colorectal cancer screening in Latino and Vietnamese Americans. Compared with non-Latino white Americans. J Gen Intern Med. 2004 Feb;19(2):156-66.

34. Perez-Stable EJ et al. Self-reported use of cancer screening tests among Latinos and Anglos in a prepaid health plan. Arch Intern Med. 1994 May 23;154(10):1073-81.

35. Shariff-Marco S et al. Racial/ethnic differences in self-reported racism and its association with cancer-related health behaviors. Am J Public Health. 2010 Feb;100(2):364-74.

36. Powe BD et al. Comparing knowledge of colorectal and prostate cancer among African American and Hispanic men. Cancer Nurs. 2009 Sep-Oct;32(5):412-7.

37. Jun J, Oh KM. Asian and Hispanic Americans’ cancer fatalism and colon cancer screening. Am J Health Behav. 2013 Mar;37(2):145-54.

38. Hacker K et al. The impact of Immigration and Customs Enforcement on immigrant health: Perceptions of immigrants in Everett, Massachusetts, USA. Soc Sci Med. 2011 Aug;73(4):586-94.

39. Firger J. Rescinding DACA could spur a public health crisis, from lost services to higher rates of depression, substance abuse. Newsweek.

40. May FP et al. Racial minorities are more likely than whites to report lack of provider recommendation for colon cancer screening. Am J Gastroenterol. 2015 Oct;110(10):1388-94.

41. Levy BT et al. Why hasn’t this patient been screened for colon cancer? An Iowa Research Network study. J Am Board Fam Med. 2007 Sep-Oct;20(5):458-68.

42. Rosenblatt RA. A view from the periphery – health care in rural America. N Engl J Med. 2004 Sep 9;351(11):1049-51.

43. Young WF et al. Predictors of colorectal screening in rural Colorado: testing to prevent colon cancer in the high plains research network. J Rural Health. 2007 Summer;23(3):238-45.

44. Kates J et al. Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals in the U.S. In: Foundation KF, ed. Disparities Policy Issue Brief. Volume 2017; Aug 30, 2017.

45. Katz ML et al. Improving colorectal cancer screening by using community volunteers: results of the Carolinas cancer education and screening (CARES) project. Cancer. 2007 Oct 1;110(7):1602-10.

46. Jean-Jacques M et al. Program to improve colorectal cancer screening in a low-income, racially diverse population: A randomized controlled trial. Ann Fam Med. 2012 Sep-Oct;10(5):412-7.

47. Reuland DS et al. Effect of combined patient decision aid and patient navigation vs usual care for colorectal cancer screening in a vulnerable patient population: A randomized clinical trial. JAMA Intern Med. 2017 Jul 1;177(7):967-74.

48. Percac-Lima S et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med. 2009 Feb;24(2):211-7.

49. Nash D et al. Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting. J Urban Health. 2006 Mar;83(2):231-43.

50. Lebwohl B et al. Effect of a patient navigator program on the volume and quality of colonoscopy. J Clin Gastroenterol. 2011 May-Jun;45(5):e47-53.

51. Khankari K et al. Improving colorectal cancer screening among the medically underserved: A pilot study within a federally qualified health center. J Gen Intern Med. 2007 Oct;22(10):1410-4.

52. Wang JH et al. Recruiting Chinese Americans into cancer screening intervention trials: Strategies and outcomes. Clin Trials. 2014 Apr;11(2):167-77.

53. Katz ML et al. Patient activation increases colorectal cancer screening rates: a randomized trial among low-income minority patients. Cancer Epidemiol Biomarkers Prev. 2012 Jan;21(1):45-52.

54. Ford ME et al. Enhancing adherence among older African American men enrolled in a longitudinal cancer screening trial. Gerontologist. 2006 Aug;46(4):545-50.

55. Christie J et al. A randomized controlled trial using patient navigation to increase colonoscopy screening among low-income minorities. J Natl Med Assoc. 2008 Mar;100(3):278-84.

56. Philip EJ et al. Evaluating the impact of an educational intervention to increase CRC screening rates in the African American community: A preliminary study. Cancer Causes Control. 2010 Oct;21(10):1685-91.

57. Greiner KA et al. Implementation intentions and colorectal screening: A randomized trial in safety-net clinics. Am J Prev Med. 2014 Dec;47(6):703-14.

58. Horne HN et al. Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults. Cancer Causes Control. 2015 Feb;26(2):239-46.

59. Grubbs SS et al. Eliminating racial disparities in colorectal cancer in the real world: It took a village. J Clin Oncol. 2013 Jun 1;31(16):1928-30.

60. Jung MY et al. The Chinese and Korean American immigrant experience: a mixed-methods examination of facilitators and barriers of colorectal cancer screening. Ethn Health. 2017 Feb 25:1-20.

61. Viruell-Fuentes EA et al. More than culture: structural racism, intersectionality theory, and immigrant health. Soc Sci Med. 2012 Dec;75(12):2099-106.

Dr. Oduyebo is a third-year fellow at the Mayo Clinic, Rochester, Minn.; Dr. Malespin is an assistant professor in the department of medicine and the medical director of hepatology at the University of Florida Health, Jacksonville; Dr. Mendoza Ladd is an assistant professor of medicine at Texas Tech University, El Paso; Dr. Day is an associate professor of medicine at the University of California, San Francisco; Dr. Charabaty is an associate professor of medicine and the director of the IBD Center in the division of gastroenterology at Medstar-Georgetown University Center, Washington; Dr. Chen is an associate professor of medicine, the director of patient safety and quality, and the director of the small-bowel endoscopy program in division of gastroenterology at Washington University, St. Louis; Dr. Carr is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia; Dr. Quezada is an assistant dean for admissions, an assistant dean for academic and multicultural affairs, and an assistant professor of medicine in the division of gastroenterology and hepatology at the University of Maryland, Baltimore; and Dr. Lamousé-Smith is a director of translational medicine, immunology, and early development at Janssen Pharmaceuticals Research and Development, Spring House, Penn.

Resource

Qaseem A, Wilt TJ, Kansagara D, et al, for the Clinical Guidelines Committee of the American College of Physicians. Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: a guidance statement update from the American College of Physicians. Ann Int Med. 2018; Mar 6. doi: 10.7326/M17-0939. [Epub ahead of print].

Resource

Qaseem A, Wilt TJ, Kansagara D, et al, for the Clinical Guidelines Committee of the American College of Physicians. Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: a guidance statement update from the American College of Physicians. Ann Int Med. 2018; Mar 6. doi: 10.7326/M17-0939. [Epub ahead of print].

Resource

Qaseem A, Wilt TJ, Kansagara D, et al, for the Clinical Guidelines Committee of the American College of Physicians. Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: a guidance statement update from the American College of Physicians. Ann Int Med. 2018; Mar 6. doi: 10.7326/M17-0939. [Epub ahead of print].

Dear Colleagues,

Welcome to the second edition of The New Gastroenterologist in its e-newsletter format! As more content in medicine, and life in general, is moving toward digital platforms, we at the AGA believe this transition will improve both content dissemination and accessibility to all our readers. In this new format, we will to continue to provide articles on topics of importance to the early-career community, expand our offerings by including the new “In Focus” articles (concise overviews of GI topics) both digitally and in GI & Hepatology News print issues, as well as increase the use of multimedia resources, such as videos, to further enhance our content.

The “In Focus” article this month is authored by the members of the AGA’s Diversity Committee and focuses on the extremely important topic of barriers preventing colorectal cancer screening in underserved populations. This comprehensive overview will undoubtedly help us in our mission to ensure valuable colorectal cancer screening is more frequently, and widely, applied. And be sure to look for it in the May print issue of GI & Hepatology News as well.

Digestive Disease Week (DDW^®), which many of us will be attending, features cutting-edge research and provides an invaluable opportunity for networking. With DDW right around the corner, Lea Ann Chen (NYU) gives some very helpful pointers to ensure that you get the most out of your experience. Additionally, David Leiman (Duke) and Neil Sengupta (University of Chicago) provide an overview of how best to incorporate new evidence into your daily practice. This is such a critical topic nowadays given the ever-growing number of journal articles published as well as the speed at which information is disseminated both throughout our field and in the popular press.

In our postfellowship pathways section, Elizabeth Verna (Columbia) provides an overview of the advanced training options available in hepatology including the new ABIM pilot program that combines a transplant hepatology fellowship year with the third year of fellowship. Finally, there is an overview on strategies for retirement savings by A.J. Bellamah (BNB Wealth Management), which is an area where so many of us get a late start due to extended training and student loan burden.

Please also check out the “In Case You Missed It” section to see selected articles published in the AGA journals, which are particularly relevant to those of us in our early careers. If you have any ideas for future articles, or are interested in contributing to The New Gastroenterologist, please contact me at bryson.katona@uphs.upenn.edu or the managing editor, Ryan Farrell, at rfarrell@gastro.org.
 

Sincerely,

Bryson W. Katona, MD, PhD

Editor in Chief

Dr. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

Dear Colleagues,

Welcome to the second edition of The New Gastroenterologist in its e-newsletter format! As more content in medicine, and life in general, is moving toward digital platforms, we at the AGA believe this transition will improve both content dissemination and accessibility to all our readers. In this new format, we will to continue to provide articles on topics of importance to the early-career community, expand our offerings by including the new “In Focus” articles (concise overviews of GI topics) both digitally and in GI & Hepatology News print issues, as well as increase the use of multimedia resources, such as videos, to further enhance our content.

The “In Focus” article this month is authored by the members of the AGA’s Diversity Committee and focuses on the extremely important topic of barriers preventing colorectal cancer screening in underserved populations. This comprehensive overview will undoubtedly help us in our mission to ensure valuable colorectal cancer screening is more frequently, and widely, applied. And be sure to look for it in the May print issue of GI & Hepatology News as well.

Digestive Disease Week (DDW^®), which many of us will be attending, features cutting-edge research and provides an invaluable opportunity for networking. With DDW right around the corner, Lea Ann Chen (NYU) gives some very helpful pointers to ensure that you get the most out of your experience. Additionally, David Leiman (Duke) and Neil Sengupta (University of Chicago) provide an overview of how best to incorporate new evidence into your daily practice. This is such a critical topic nowadays given the ever-growing number of journal articles published as well as the speed at which information is disseminated both throughout our field and in the popular press.

In our postfellowship pathways section, Elizabeth Verna (Columbia) provides an overview of the advanced training options available in hepatology including the new ABIM pilot program that combines a transplant hepatology fellowship year with the third year of fellowship. Finally, there is an overview on strategies for retirement savings by A.J. Bellamah (BNB Wealth Management), which is an area where so many of us get a late start due to extended training and student loan burden.

Please also check out the “In Case You Missed It” section to see selected articles published in the AGA journals, which are particularly relevant to those of us in our early careers. If you have any ideas for future articles, or are interested in contributing to The New Gastroenterologist, please contact me at bryson.katona@uphs.upenn.edu or the managing editor, Ryan Farrell, at rfarrell@gastro.org.
 

Sincerely,

Bryson W. Katona, MD, PhD

Editor in Chief

Dr. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

Dear Colleagues,

Welcome to the second edition of The New Gastroenterologist in its e-newsletter format! As more content in medicine, and life in general, is moving toward digital platforms, we at the AGA believe this transition will improve both content dissemination and accessibility to all our readers. In this new format, we will to continue to provide articles on topics of importance to the early-career community, expand our offerings by including the new “In Focus” articles (concise overviews of GI topics) both digitally and in GI & Hepatology News print issues, as well as increase the use of multimedia resources, such as videos, to further enhance our content.

The “In Focus” article this month is authored by the members of the AGA’s Diversity Committee and focuses on the extremely important topic of barriers preventing colorectal cancer screening in underserved populations. This comprehensive overview will undoubtedly help us in our mission to ensure valuable colorectal cancer screening is more frequently, and widely, applied. And be sure to look for it in the May print issue of GI & Hepatology News as well.

Digestive Disease Week (DDW^®), which many of us will be attending, features cutting-edge research and provides an invaluable opportunity for networking. With DDW right around the corner, Lea Ann Chen (NYU) gives some very helpful pointers to ensure that you get the most out of your experience. Additionally, David Leiman (Duke) and Neil Sengupta (University of Chicago) provide an overview of how best to incorporate new evidence into your daily practice. This is such a critical topic nowadays given the ever-growing number of journal articles published as well as the speed at which information is disseminated both throughout our field and in the popular press.

In our postfellowship pathways section, Elizabeth Verna (Columbia) provides an overview of the advanced training options available in hepatology including the new ABIM pilot program that combines a transplant hepatology fellowship year with the third year of fellowship. Finally, there is an overview on strategies for retirement savings by A.J. Bellamah (BNB Wealth Management), which is an area where so many of us get a late start due to extended training and student loan burden.

Please also check out the “In Case You Missed It” section to see selected articles published in the AGA journals, which are particularly relevant to those of us in our early careers. If you have any ideas for future articles, or are interested in contributing to The New Gastroenterologist, please contact me at bryson.katona@uphs.upenn.edu or the managing editor, Ryan Farrell, at rfarrell@gastro.org.
 

Sincerely,

Bryson W. Katona, MD, PhD

Editor in Chief

Dr. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

Heavy drinking was not associated with higher proportions of liver-related deaths or liver transplantation among patients with drug-induced liver injury (DILI), according to the results of a prospective multicenter cohort study reported in the May issue of Clinical Gastroenterology and Hepatology.

Anabolic steroids were the most common cause of DILI among heavy drinkers, defined as men who averaged more than three drinks a day or women who averaged more than two drinks daily, said Lara Dakhoul, MD, of Indiana University, Indianapolis, and her associates. There also was no evidence that heavy alcohol consumption increased the risk of liver injury attributable to isoniazid exposure, the researchers wrote in.

Although consuming alcohol significantly increases the risk of acetaminophen-induced liver injury, there is much less clarity about the relationship between drinking and hepatotoxicity from drugs such as duloxetine or antituberculosis medications, the researchers noted. In fact, one recent study found that drinking led to less severe liver injury among individuals with DILI. To better elucidate these links, the investigators studied 1,198 individuals with confirmed or probable DILI who enrolled in the DILI Network study (DILIN) between 2004 and 2016. At enrollment, all participants were asked if they consumed alcohol, and those who reported drinking within the past 12 months were offered a shortened version of the Skinner Alcohol Dependence Scale to collect details on alcohol consumption, including type, amount, and frequency.

In all, 601 persons reported consuming at least one alcoholic drink in the preceding year, of whom 348 completed the Skinner questionnaire. A total of 80 individuals reported heavy alcohol consumption. Heavy drinkers were typically in their early 40s, while nondrinkers tended to be nearly 50 years old (P less than .01). Heavy drinkers were also more often men (63%) while nondrinkers were usually women (65%; P less than .01). Heavy drinkers were significantly more likely to have DILI secondary to anabolic steroid exposure (13%) than were nondrinkers (2%; P less than .001). However, latency, pattern of liver injury, peak enzyme levels, and patterns of recovery from steroid hepatotoxicity were similar regardless of alcohol history.

A total of eight patients with DILI died of liver-related causes or underwent liver transplantation, and proportions of patients with these outcomes were similar regardless of alcohol history. These eight patients had no evidence of hepatitis C virus infection, but three appeared to have underlying alcoholic liver disease with superimposed acute-on-chronic liver failure. Heavy drinkers did not have significantly higher DILI severity scores than nondrinkers, but they did have significantly higher peak serum levels of alanine aminotransferase (1,323 U/L vs. 754, respectively; P = .02) and significantly higher levels of bilirubin (16.1 vs. 12.7 mg/dL; P = .03).

The two fatal cases of DILI among heavy drinkers involved a 44-year-old man with underlying alcoholic cirrhosis and steatohepatitis who developed acute-on-chronic liver failure 11 days after starting niacin, and a 76-year-old man with chronic obstructive pulmonary disease and bronchitis flare who developed severe liver injury and skin rash 6 days after starting azithromycin.

The study was not able to assess whether heavy alcohol consumption contributed to liver injury from specific agents, the researchers said. Additionally, a substantial number of drinkers did not complete the Skinner questionnaire, and those who did might have underestimated or underreported their own alcohol consumption. “Counterbalancing these issues are the [study’s] unique strengths, such as prospective design, larger sample size, well-characterized DILI phenotype, and careful, structured adjudication of causality and severity,” the researchers wrote.

SOURCE: Dakhoul L et al. Clin Gastro Hepatol. 2018 Jan 3. doi: 10.1016/j.cgh.2017.12.036.

Heavy drinking was not associated with higher proportions of liver-related deaths or liver transplantation among patients with drug-induced liver injury (DILI), according to the results of a prospective multicenter cohort study reported in the May issue of Clinical Gastroenterology and Hepatology.

Anabolic steroids were the most common cause of DILI among heavy drinkers, defined as men who averaged more than three drinks a day or women who averaged more than two drinks daily, said Lara Dakhoul, MD, of Indiana University, Indianapolis, and her associates. There also was no evidence that heavy alcohol consumption increased the risk of liver injury attributable to isoniazid exposure, the researchers wrote in.

Although consuming alcohol significantly increases the risk of acetaminophen-induced liver injury, there is much less clarity about the relationship between drinking and hepatotoxicity from drugs such as duloxetine or antituberculosis medications, the researchers noted. In fact, one recent study found that drinking led to less severe liver injury among individuals with DILI. To better elucidate these links, the investigators studied 1,198 individuals with confirmed or probable DILI who enrolled in the DILI Network study (DILIN) between 2004 and 2016. At enrollment, all participants were asked if they consumed alcohol, and those who reported drinking within the past 12 months were offered a shortened version of the Skinner Alcohol Dependence Scale to collect details on alcohol consumption, including type, amount, and frequency.

In all, 601 persons reported consuming at least one alcoholic drink in the preceding year, of whom 348 completed the Skinner questionnaire. A total of 80 individuals reported heavy alcohol consumption. Heavy drinkers were typically in their early 40s, while nondrinkers tended to be nearly 50 years old (P less than .01). Heavy drinkers were also more often men (63%) while nondrinkers were usually women (65%; P less than .01). Heavy drinkers were significantly more likely to have DILI secondary to anabolic steroid exposure (13%) than were nondrinkers (2%; P less than .001). However, latency, pattern of liver injury, peak enzyme levels, and patterns of recovery from steroid hepatotoxicity were similar regardless of alcohol history.

A total of eight patients with DILI died of liver-related causes or underwent liver transplantation, and proportions of patients with these outcomes were similar regardless of alcohol history. These eight patients had no evidence of hepatitis C virus infection, but three appeared to have underlying alcoholic liver disease with superimposed acute-on-chronic liver failure. Heavy drinkers did not have significantly higher DILI severity scores than nondrinkers, but they did have significantly higher peak serum levels of alanine aminotransferase (1,323 U/L vs. 754, respectively; P = .02) and significantly higher levels of bilirubin (16.1 vs. 12.7 mg/dL; P = .03).

The two fatal cases of DILI among heavy drinkers involved a 44-year-old man with underlying alcoholic cirrhosis and steatohepatitis who developed acute-on-chronic liver failure 11 days after starting niacin, and a 76-year-old man with chronic obstructive pulmonary disease and bronchitis flare who developed severe liver injury and skin rash 6 days after starting azithromycin.

The study was not able to assess whether heavy alcohol consumption contributed to liver injury from specific agents, the researchers said. Additionally, a substantial number of drinkers did not complete the Skinner questionnaire, and those who did might have underestimated or underreported their own alcohol consumption. “Counterbalancing these issues are the [study’s] unique strengths, such as prospective design, larger sample size, well-characterized DILI phenotype, and careful, structured adjudication of causality and severity,” the researchers wrote.

SOURCE: Dakhoul L et al. Clin Gastro Hepatol. 2018 Jan 3. doi: 10.1016/j.cgh.2017.12.036.

Heavy drinking was not associated with higher proportions of liver-related deaths or liver transplantation among patients with drug-induced liver injury (DILI), according to the results of a prospective multicenter cohort study reported in the May issue of Clinical Gastroenterology and Hepatology.

Anabolic steroids were the most common cause of DILI among heavy drinkers, defined as men who averaged more than three drinks a day or women who averaged more than two drinks daily, said Lara Dakhoul, MD, of Indiana University, Indianapolis, and her associates. There also was no evidence that heavy alcohol consumption increased the risk of liver injury attributable to isoniazid exposure, the researchers wrote in.

Although consuming alcohol significantly increases the risk of acetaminophen-induced liver injury, there is much less clarity about the relationship between drinking and hepatotoxicity from drugs such as duloxetine or antituberculosis medications, the researchers noted. In fact, one recent study found that drinking led to less severe liver injury among individuals with DILI. To better elucidate these links, the investigators studied 1,198 individuals with confirmed or probable DILI who enrolled in the DILI Network study (DILIN) between 2004 and 2016. At enrollment, all participants were asked if they consumed alcohol, and those who reported drinking within the past 12 months were offered a shortened version of the Skinner Alcohol Dependence Scale to collect details on alcohol consumption, including type, amount, and frequency.

In all, 601 persons reported consuming at least one alcoholic drink in the preceding year, of whom 348 completed the Skinner questionnaire. A total of 80 individuals reported heavy alcohol consumption. Heavy drinkers were typically in their early 40s, while nondrinkers tended to be nearly 50 years old (P less than .01). Heavy drinkers were also more often men (63%) while nondrinkers were usually women (65%; P less than .01). Heavy drinkers were significantly more likely to have DILI secondary to anabolic steroid exposure (13%) than were nondrinkers (2%; P less than .001). However, latency, pattern of liver injury, peak enzyme levels, and patterns of recovery from steroid hepatotoxicity were similar regardless of alcohol history.

A total of eight patients with DILI died of liver-related causes or underwent liver transplantation, and proportions of patients with these outcomes were similar regardless of alcohol history. These eight patients had no evidence of hepatitis C virus infection, but three appeared to have underlying alcoholic liver disease with superimposed acute-on-chronic liver failure. Heavy drinkers did not have significantly higher DILI severity scores than nondrinkers, but they did have significantly higher peak serum levels of alanine aminotransferase (1,323 U/L vs. 754, respectively; P = .02) and significantly higher levels of bilirubin (16.1 vs. 12.7 mg/dL; P = .03).

The two fatal cases of DILI among heavy drinkers involved a 44-year-old man with underlying alcoholic cirrhosis and steatohepatitis who developed acute-on-chronic liver failure 11 days after starting niacin, and a 76-year-old man with chronic obstructive pulmonary disease and bronchitis flare who developed severe liver injury and skin rash 6 days after starting azithromycin.

The study was not able to assess whether heavy alcohol consumption contributed to liver injury from specific agents, the researchers said. Additionally, a substantial number of drinkers did not complete the Skinner questionnaire, and those who did might have underestimated or underreported their own alcohol consumption. “Counterbalancing these issues are the [study’s] unique strengths, such as prospective design, larger sample size, well-characterized DILI phenotype, and careful, structured adjudication of causality and severity,” the researchers wrote.

SOURCE: Dakhoul L et al. Clin Gastro Hepatol. 2018 Jan 3. doi: 10.1016/j.cgh.2017.12.036.

The Food and Drug Administration has approved a new indication for the chronic obstructive pulmonary disease (COPD) therapy fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta), which allows physicians to prescribe the drug to a broader class of COPD patients, according to a statement from two pharmaceutical companies.

copyright designer491/Thinkstock

klennon@mdedge.com

The Food and Drug Administration has approved a new indication for the chronic obstructive pulmonary disease (COPD) therapy fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta), which allows physicians to prescribe the drug to a broader class of COPD patients, according to a statement from two pharmaceutical companies.

copyright designer491/Thinkstock

klennon@mdedge.com

The Food and Drug Administration has approved a new indication for the chronic obstructive pulmonary disease (COPD) therapy fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta), which allows physicians to prescribe the drug to a broader class of COPD patients, according to a statement from two pharmaceutical companies.

copyright designer491/Thinkstock

klennon@mdedge.com

WASHINGTON – Medical aid in dying is not the same as suicide; it is a way to give people with terminal illness and facing imminent death a way to die better and avoid the terrible, drawn-out deaths from chronic disease that often now occur, Margaret P. Battin, PhD, said at the annual conference of the American Association of Suicidology.

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

mzoler@mdedge.com

WASHINGTON – Medical aid in dying is not the same as suicide; it is a way to give people with terminal illness and facing imminent death a way to die better and avoid the terrible, drawn-out deaths from chronic disease that often now occur, Margaret P. Battin, PhD, said at the annual conference of the American Association of Suicidology.

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

mzoler@mdedge.com

WASHINGTON – Medical aid in dying is not the same as suicide; it is a way to give people with terminal illness and facing imminent death a way to die better and avoid the terrible, drawn-out deaths from chronic disease that often now occur, Margaret P. Battin, PhD, said at the annual conference of the American Association of Suicidology.

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

mzoler@mdedge.com

Penile squamous cell carcinoma (SCC) with considerable urethral extension is uncommon and difficult to manage. It often is resistant to less invasive and nonsurgical treatments and frequently results in partial or total penectomy, which can lead to cosmetic disfigurement, functional issues, and psychological distress. We report a case of penile SCC in situ with considerable urethral extension with a focus of cells suspicious for moderately well-differentiated and invasive SCC that was treated with Mohs micrographic surgery (MMS).

Mohs micrographic surgery with distal urethrectomy and reconstruction is a valuable treatment technique for cases of SCC involving the glans penis and distal urethra. It offers equivalent or better overall cure rates compared to more radical interventions. Additionally, preservation of the penis with MMS spares patients from considerable physical and psychosocial morbidity. Our case, along with growing body of literature,^1-4 calls on dermatologists and urologists to consider MMS as a treatment for penile SCC with or without urethral involvement.

Case Report

A 61-year-old man presented to the dermatology department with a pruritic lesion on the penis that had been present for 6 years. Shave biopsy demonstrated SCC in situ with a focus of cells suspicious for moderately well-differentiated and invasive SCC. Physical examination revealed an ill-defined, 2.2×1.9-cm, pink, eroded plaque involving the tip of the penis and surrounding the external urinary meatus (Figure 1). There was no palpable inguinal lymphadenopathy.

Distal penectomy and lymph node biopsy was recommended following evaluation by the urologic oncology department, but the patient declined these interventions and presented to our dermatology department (A.H.) for a second opinion. The tumor, including the invasive perineural portion, was removed using MMS several weeks after initially presenting to urologic oncology. Ventral meatotomy allowed access to the SCC in situ portion extending proximally up the pendulous urethra (Figure 2). Clear margins were obtained after the eighth stage of MMS, which required removal of 4 to 5 cm of the distal urethra (Figure 3). Reconstruction of the wound required urethral advancement, urethrostomy, and meatoplasty. A positive outcome was achieved with preservation of the length and shape of the penis as well as the cosmetic appearance of the glans penis (Figure 4). The patient was satisfied with the outcome. At 49 months’ follow-up, no evidence of local recurrence or disease progression was noted, and the distal urethrostomy remained intact and functional.

Comment

Penile SCC is a rare malignancy that represents between 0.4% and 0.6% of all malignant tumors in the United States and occurs most commonly in men aged 50 to 70 years.⁴ The incidence is higher in developing countries, approaching 10% of malignancies in men. It occurs most commonly on the glans penis, prepuce, and coronal sulcus, and has multiple possible appearances, including erythematous and indurated, warty and exophytic, or flat and ulcerated lesions.⁵ Some reports indicate that more than 40% of penile SCCs are attributable to human papilloma virus,⁶ while lack of circumcision, chronic inflammation, poor hygiene, balanitis xerotica obliterans, penile trauma, human immunodeficiency virus, UVA treatment of penile psoriasis, and tobacco use are known risk factors.⁵

Invasive penile SCC generally is treated with penectomy (partial or total), radiation therapy, or MMS; SCC in situ can be treated with topical chemotherapy, laser therapy, and wide local excision (2-cm margins) including circumcision, complete glansectomy, or MMS.⁵ Squamous cell carcinoma in situ with urethral involvement treated with nonsurgical therapies is associated with higher recurrence rates, ultimately necessitating more aggressive treatments, most commonly partial penectomy.⁷ The high local recurrence rate of SCC in situ with urethral involvement treated with nonsurgical therapies reflects the fact that determining the presence of urethral extension is difficult and, if present, is inherently inaccessible to these local therapies because the urethra is not an outward-facing tissue surface; MMS represents one possible solution to these issues.

Across all treatment modalities, the most prognostic factor of cancer-specific survival in patients with penile SCC is pelvic lymph node involvement. Some reports cite 5-year survival rates as low as 0% in the setting of pelvic lymph node involvement,⁵ whereas others had cited rates of 29% to 40%⁴; 5-year survival rates of higher than 85% have been reported in node-negative patients.⁴ Recurrence rates vary widely by treatment modality, ranging from less than 10% with partial penectomy and long-term follow-up⁸ and up to 50% within 2 years with penile-preserving approaches (eg, topical chemotherapy, laser therapy, radiotherapy).⁵ Multiple case series of penile cancer (the most common of which was SCC/SCC in situ) treated with MMS report comparable and at times superior survival and recurrence data (Table).^1-4 Slightly higher recurrences of penile SCC treated with MMS compared to penectomy have been reported, along with considerably higher recurrence rates compared to nonpenile cutaneous SCC treated with MMS (reported to be less than 3%).⁴ The elastic and expansile nature of penile tissue may lead to distortion from swelling/local anesthesia when taking individual Mohs layers. Additionally, as a large percentage of penile SCCs are attributable to human papillomavirus, difficulty in detecting human papilloma virus–infected cells (which may have oncogenic potential) with the naked eye or histologically with typical staining techniques may help explain the higher recurrence rate of penile SCC treated with MMS compared to penectomy. Despite the higher recurrence rates, survival is comparable or higher in cases treated with MMS (Table).

Partial penectomy also has a negative impact on health-related quality of life. Kieffer et al⁹ compared the impact of penile-sparing surgery (PSS)(including MMS) versus partial or total penectomy on sexual function and health-related quality of life in 90 patients with penile cancer. Although the association between the extent of surgery (partial penectomy/total penectomy/PSS) surgery type and extent and most outcome measures was not statistically significant, partial penectomy was associated with significantly more problems with orgasm (P=.031), concerns about appearance (P=.008), interference in daily life (P=.032), and urinary function (P<.0001) when compared to patients treated with PSS.⁹ Although this study included only laser/local excision with or without circumcision or glans penis amputation with or without reconstruction as PSSs and did not explicitly include MMS, MMS is clearly a tissue-sparing technique and the study results are generalizable to MMS. The fact that MMS was not included as a PSS also may underscore the fact that MMS for penile cancer may not yet be available in certain regions; this study was conducted in the Netherlands.

Conclusion

Penile SCC with considerable urethral extension is uncommon, difficult to manage, and often is resistant to less invasive and nonsurgical treatments. As a result, partial or total penectomy is sometimes necessary. Such cases benefit from MMS with distal urethrectomy and reconstruction because MMS provides equivalent or better overall cure rates compared to more radical interventions.^1-4 Importantly, preservation of the penis with MMS can spare patients considerable physical and psychosocial morbidity. Partial penectomy is associated with more health-related quality-of-life problems with orgasm, concerns about appearance, interference in daily life, and urinary function compared to PSSs such as MMS.⁹ This case, and a growing body of literature, are a call to dermatologists and urologists to consider MMS as a treatment for penile SCC, even with involvement of the urethra.

Penile squamous cell carcinoma (SCC) with considerable urethral extension is uncommon and difficult to manage. It often is resistant to less invasive and nonsurgical treatments and frequently results in partial or total penectomy, which can lead to cosmetic disfigurement, functional issues, and psychological distress. We report a case of penile SCC in situ with considerable urethral extension with a focus of cells suspicious for moderately well-differentiated and invasive SCC that was treated with Mohs micrographic surgery (MMS).

Mohs micrographic surgery with distal urethrectomy and reconstruction is a valuable treatment technique for cases of SCC involving the glans penis and distal urethra. It offers equivalent or better overall cure rates compared to more radical interventions. Additionally, preservation of the penis with MMS spares patients from considerable physical and psychosocial morbidity. Our case, along with growing body of literature,^1-4 calls on dermatologists and urologists to consider MMS as a treatment for penile SCC with or without urethral involvement.

Case Report

A 61-year-old man presented to the dermatology department with a pruritic lesion on the penis that had been present for 6 years. Shave biopsy demonstrated SCC in situ with a focus of cells suspicious for moderately well-differentiated and invasive SCC. Physical examination revealed an ill-defined, 2.2×1.9-cm, pink, eroded plaque involving the tip of the penis and surrounding the external urinary meatus (Figure 1). There was no palpable inguinal lymphadenopathy.

Distal penectomy and lymph node biopsy was recommended following evaluation by the urologic oncology department, but the patient declined these interventions and presented to our dermatology department (A.H.) for a second opinion. The tumor, including the invasive perineural portion, was removed using MMS several weeks after initially presenting to urologic oncology. Ventral meatotomy allowed access to the SCC in situ portion extending proximally up the pendulous urethra (Figure 2). Clear margins were obtained after the eighth stage of MMS, which required removal of 4 to 5 cm of the distal urethra (Figure 3). Reconstruction of the wound required urethral advancement, urethrostomy, and meatoplasty. A positive outcome was achieved with preservation of the length and shape of the penis as well as the cosmetic appearance of the glans penis (Figure 4). The patient was satisfied with the outcome. At 49 months’ follow-up, no evidence of local recurrence or disease progression was noted, and the distal urethrostomy remained intact and functional.

Comment

Penile SCC is a rare malignancy that represents between 0.4% and 0.6% of all malignant tumors in the United States and occurs most commonly in men aged 50 to 70 years.⁴ The incidence is higher in developing countries, approaching 10% of malignancies in men. It occurs most commonly on the glans penis, prepuce, and coronal sulcus, and has multiple possible appearances, including erythematous and indurated, warty and exophytic, or flat and ulcerated lesions.⁵ Some reports indicate that more than 40% of penile SCCs are attributable to human papilloma virus,⁶ while lack of circumcision, chronic inflammation, poor hygiene, balanitis xerotica obliterans, penile trauma, human immunodeficiency virus, UVA treatment of penile psoriasis, and tobacco use are known risk factors.⁵

Invasive penile SCC generally is treated with penectomy (partial or total), radiation therapy, or MMS; SCC in situ can be treated with topical chemotherapy, laser therapy, and wide local excision (2-cm margins) including circumcision, complete glansectomy, or MMS.⁵ Squamous cell carcinoma in situ with urethral involvement treated with nonsurgical therapies is associated with higher recurrence rates, ultimately necessitating more aggressive treatments, most commonly partial penectomy.⁷ The high local recurrence rate of SCC in situ with urethral involvement treated with nonsurgical therapies reflects the fact that determining the presence of urethral extension is difficult and, if present, is inherently inaccessible to these local therapies because the urethra is not an outward-facing tissue surface; MMS represents one possible solution to these issues.

Across all treatment modalities, the most prognostic factor of cancer-specific survival in patients with penile SCC is pelvic lymph node involvement. Some reports cite 5-year survival rates as low as 0% in the setting of pelvic lymph node involvement,⁵ whereas others had cited rates of 29% to 40%⁴; 5-year survival rates of higher than 85% have been reported in node-negative patients.⁴ Recurrence rates vary widely by treatment modality, ranging from less than 10% with partial penectomy and long-term follow-up⁸ and up to 50% within 2 years with penile-preserving approaches (eg, topical chemotherapy, laser therapy, radiotherapy).⁵ Multiple case series of penile cancer (the most common of which was SCC/SCC in situ) treated with MMS report comparable and at times superior survival and recurrence data (Table).^1-4 Slightly higher recurrences of penile SCC treated with MMS compared to penectomy have been reported, along with considerably higher recurrence rates compared to nonpenile cutaneous SCC treated with MMS (reported to be less than 3%).⁴ The elastic and expansile nature of penile tissue may lead to distortion from swelling/local anesthesia when taking individual Mohs layers. Additionally, as a large percentage of penile SCCs are attributable to human papillomavirus, difficulty in detecting human papilloma virus–infected cells (which may have oncogenic potential) with the naked eye or histologically with typical staining techniques may help explain the higher recurrence rate of penile SCC treated with MMS compared to penectomy. Despite the higher recurrence rates, survival is comparable or higher in cases treated with MMS (Table).

Partial penectomy also has a negative impact on health-related quality of life. Kieffer et al⁹ compared the impact of penile-sparing surgery (PSS)(including MMS) versus partial or total penectomy on sexual function and health-related quality of life in 90 patients with penile cancer. Although the association between the extent of surgery (partial penectomy/total penectomy/PSS) surgery type and extent and most outcome measures was not statistically significant, partial penectomy was associated with significantly more problems with orgasm (P=.031), concerns about appearance (P=.008), interference in daily life (P=.032), and urinary function (P<.0001) when compared to patients treated with PSS.⁹ Although this study included only laser/local excision with or without circumcision or glans penis amputation with or without reconstruction as PSSs and did not explicitly include MMS, MMS is clearly a tissue-sparing technique and the study results are generalizable to MMS. The fact that MMS was not included as a PSS also may underscore the fact that MMS for penile cancer may not yet be available in certain regions; this study was conducted in the Netherlands.

Conclusion

Penile SCC with considerable urethral extension is uncommon, difficult to manage, and often is resistant to less invasive and nonsurgical treatments. As a result, partial or total penectomy is sometimes necessary. Such cases benefit from MMS with distal urethrectomy and reconstruction because MMS provides equivalent or better overall cure rates compared to more radical interventions.^1-4 Importantly, preservation of the penis with MMS can spare patients considerable physical and psychosocial morbidity. Partial penectomy is associated with more health-related quality-of-life problems with orgasm, concerns about appearance, interference in daily life, and urinary function compared to PSSs such as MMS.⁹ This case, and a growing body of literature, are a call to dermatologists and urologists to consider MMS as a treatment for penile SCC, even with involvement of the urethra.

Penile squamous cell carcinoma (SCC) with considerable urethral extension is uncommon and difficult to manage. It often is resistant to less invasive and nonsurgical treatments and frequently results in partial or total penectomy, which can lead to cosmetic disfigurement, functional issues, and psychological distress. We report a case of penile SCC in situ with considerable urethral extension with a focus of cells suspicious for moderately well-differentiated and invasive SCC that was treated with Mohs micrographic surgery (MMS).

Mohs micrographic surgery with distal urethrectomy and reconstruction is a valuable treatment technique for cases of SCC involving the glans penis and distal urethra. It offers equivalent or better overall cure rates compared to more radical interventions. Additionally, preservation of the penis with MMS spares patients from considerable physical and psychosocial morbidity. Our case, along with growing body of literature,^1-4 calls on dermatologists and urologists to consider MMS as a treatment for penile SCC with or without urethral involvement.

Case Report

A 61-year-old man presented to the dermatology department with a pruritic lesion on the penis that had been present for 6 years. Shave biopsy demonstrated SCC in situ with a focus of cells suspicious for moderately well-differentiated and invasive SCC. Physical examination revealed an ill-defined, 2.2×1.9-cm, pink, eroded plaque involving the tip of the penis and surrounding the external urinary meatus (Figure 1). There was no palpable inguinal lymphadenopathy.

Distal penectomy and lymph node biopsy was recommended following evaluation by the urologic oncology department, but the patient declined these interventions and presented to our dermatology department (A.H.) for a second opinion. The tumor, including the invasive perineural portion, was removed using MMS several weeks after initially presenting to urologic oncology. Ventral meatotomy allowed access to the SCC in situ portion extending proximally up the pendulous urethra (Figure 2). Clear margins were obtained after the eighth stage of MMS, which required removal of 4 to 5 cm of the distal urethra (Figure 3). Reconstruction of the wound required urethral advancement, urethrostomy, and meatoplasty. A positive outcome was achieved with preservation of the length and shape of the penis as well as the cosmetic appearance of the glans penis (Figure 4). The patient was satisfied with the outcome. At 49 months’ follow-up, no evidence of local recurrence or disease progression was noted, and the distal urethrostomy remained intact and functional.

Comment

Penile SCC is a rare malignancy that represents between 0.4% and 0.6% of all malignant tumors in the United States and occurs most commonly in men aged 50 to 70 years.⁴ The incidence is higher in developing countries, approaching 10% of malignancies in men. It occurs most commonly on the glans penis, prepuce, and coronal sulcus, and has multiple possible appearances, including erythematous and indurated, warty and exophytic, or flat and ulcerated lesions.⁵ Some reports indicate that more than 40% of penile SCCs are attributable to human papilloma virus,⁶ while lack of circumcision, chronic inflammation, poor hygiene, balanitis xerotica obliterans, penile trauma, human immunodeficiency virus, UVA treatment of penile psoriasis, and tobacco use are known risk factors.⁵

Invasive penile SCC generally is treated with penectomy (partial or total), radiation therapy, or MMS; SCC in situ can be treated with topical chemotherapy, laser therapy, and wide local excision (2-cm margins) including circumcision, complete glansectomy, or MMS.⁵ Squamous cell carcinoma in situ with urethral involvement treated with nonsurgical therapies is associated with higher recurrence rates, ultimately necessitating more aggressive treatments, most commonly partial penectomy.⁷ The high local recurrence rate of SCC in situ with urethral involvement treated with nonsurgical therapies reflects the fact that determining the presence of urethral extension is difficult and, if present, is inherently inaccessible to these local therapies because the urethra is not an outward-facing tissue surface; MMS represents one possible solution to these issues.

Across all treatment modalities, the most prognostic factor of cancer-specific survival in patients with penile SCC is pelvic lymph node involvement. Some reports cite 5-year survival rates as low as 0% in the setting of pelvic lymph node involvement,⁵ whereas others had cited rates of 29% to 40%⁴; 5-year survival rates of higher than 85% have been reported in node-negative patients.⁴ Recurrence rates vary widely by treatment modality, ranging from less than 10% with partial penectomy and long-term follow-up⁸ and up to 50% within 2 years with penile-preserving approaches (eg, topical chemotherapy, laser therapy, radiotherapy).⁵ Multiple case series of penile cancer (the most common of which was SCC/SCC in situ) treated with MMS report comparable and at times superior survival and recurrence data (Table).^1-4 Slightly higher recurrences of penile SCC treated with MMS compared to penectomy have been reported, along with considerably higher recurrence rates compared to nonpenile cutaneous SCC treated with MMS (reported to be less than 3%).⁴ The elastic and expansile nature of penile tissue may lead to distortion from swelling/local anesthesia when taking individual Mohs layers. Additionally, as a large percentage of penile SCCs are attributable to human papillomavirus, difficulty in detecting human papilloma virus–infected cells (which may have oncogenic potential) with the naked eye or histologically with typical staining techniques may help explain the higher recurrence rate of penile SCC treated with MMS compared to penectomy. Despite the higher recurrence rates, survival is comparable or higher in cases treated with MMS (Table).

Partial penectomy also has a negative impact on health-related quality of life. Kieffer et al⁹ compared the impact of penile-sparing surgery (PSS)(including MMS) versus partial or total penectomy on sexual function and health-related quality of life in 90 patients with penile cancer. Although the association between the extent of surgery (partial penectomy/total penectomy/PSS) surgery type and extent and most outcome measures was not statistically significant, partial penectomy was associated with significantly more problems with orgasm (P=.031), concerns about appearance (P=.008), interference in daily life (P=.032), and urinary function (P<.0001) when compared to patients treated with PSS.⁹ Although this study included only laser/local excision with or without circumcision or glans penis amputation with or without reconstruction as PSSs and did not explicitly include MMS, MMS is clearly a tissue-sparing technique and the study results are generalizable to MMS. The fact that MMS was not included as a PSS also may underscore the fact that MMS for penile cancer may not yet be available in certain regions; this study was conducted in the Netherlands.

Conclusion

Penile SCC with considerable urethral extension is uncommon, difficult to manage, and often is resistant to less invasive and nonsurgical treatments. As a result, partial or total penectomy is sometimes necessary. Such cases benefit from MMS with distal urethrectomy and reconstruction because MMS provides equivalent or better overall cure rates compared to more radical interventions.^1-4 Importantly, preservation of the penis with MMS can spare patients considerable physical and psychosocial morbidity. Partial penectomy is associated with more health-related quality-of-life problems with orgasm, concerns about appearance, interference in daily life, and urinary function compared to PSSs such as MMS.⁹ This case, and a growing body of literature, are a call to dermatologists and urologists to consider MMS as a treatment for penile SCC, even with involvement of the urethra.

Twenty percent of children insured by Medicaid received a psychiatric diagnosis before 8 years of age, according to data from more than 35,000 Medicaid-insured children in a mid-Atlantic state.

Previous cross-sectional studies have addressed trends in psychiatric treatment of children. “However, little is known about the longitudinal patterns of pediatric use of psychiatric services,” wrote Dinci Pennap, MPH, of the University of Maryland, Baltimore, and her colleagues.

juststock/gettyimages

SOURCE: Pennap D et al. JAMA Pediatr. 2018. doi: 10.1001/jamapediatrics.2018.0240.

Twenty percent of children insured by Medicaid received a psychiatric diagnosis before 8 years of age, according to data from more than 35,000 Medicaid-insured children in a mid-Atlantic state.

Previous cross-sectional studies have addressed trends in psychiatric treatment of children. “However, little is known about the longitudinal patterns of pediatric use of psychiatric services,” wrote Dinci Pennap, MPH, of the University of Maryland, Baltimore, and her colleagues.

juststock/gettyimages

SOURCE: Pennap D et al. JAMA Pediatr. 2018. doi: 10.1001/jamapediatrics.2018.0240.

Twenty percent of children insured by Medicaid received a psychiatric diagnosis before 8 years of age, according to data from more than 35,000 Medicaid-insured children in a mid-Atlantic state.

Previous cross-sectional studies have addressed trends in psychiatric treatment of children. “However, little is known about the longitudinal patterns of pediatric use of psychiatric services,” wrote Dinci Pennap, MPH, of the University of Maryland, Baltimore, and her colleagues.

juststock/gettyimages

SOURCE: Pennap D et al. JAMA Pediatr. 2018. doi: 10.1001/jamapediatrics.2018.0240.

Recent clinical guidelines have expanded not only the pool of patients who should be tested for Helicobacter pylori infection, but also the number of first-line treatment strategies clinicians should consider.

The American College of Gastroenterology guidelines from 2007 recommended just two treatments: clarithromycin-based triple therapy or bismuth-based quadruple therapy.

The 2017 update to ACG guidelines adds five additional recommended treatment possibilities, not all of which have been well studied in U.S. clinical practice, Colin W. Howden, MD, AGAF, said in a presentation at the inaugural Perspectives in Digestive Diseases meeting held by Global Academy for Medical Education.

“There are a variety of options, and unfortunately for us as practitioners, antibiotic sensitivity testing is not routinely or easily available in contemporary U.S. practice,” said Dr. Howden, professor of medicine–gastroenterology at the University of Tennessee Health Sciences Center, Memphis.

Dr. Howden, a coauthor of the latest ACG guidelines, said asking two pointed questions outlined in the document can help simplify the treatment decision:

• Is there a penicillin allergy?
• Has there been previous macrolide exposure?

“The ideal situation is that the patient is not penicillin allergic, and they’ve never had a macrolide before,” Dr. Howden said. In that case, bismuth-based quadruple therapy would be an appropriate choice.

“Bismuth quadruple therapy is never the wrong answer,” he added.

Clarithromycin-based triple therapy might be considered, according to Dr. Howden, if the local rate of resistance to H. pylori is known to be low.

Bismuth-based quadruple therapy consists of a proton pump inhibitor (PPI) or H₂ blocker, bismuth, tetracycline, and metronidazole for 10-14 days, while clarithromycin triple therapy consists of a PPI, clarithromycin, and amoxicillin or metronidazole for 10-14 days.

Several other options recently added to the guidelines have been tried in this scenario, he noted, including concomitant therapy, which consists of a PPI, clarithromycin, amoxicillin, and metronidazole for 10-14 days.

If there has been previous macrolide use but the patient is not penicillin allergic, bismuth quadruple therapy is again recommended, Dr. Howden said, and an additional approach might be the introduction of a levofloxacin-based regimen, as outlined in the guidelines.

Conversely, if there has been no previous macrolide use but the patient is confirmed to be penicillin allergic, the current guideline-recommended options are limited to bismuth quadruple therapy, or clarithromycin triple therapy with metronidazole instead of amoxicillin, Dr. Howden said at the meeting.

Finally, for penicillin-allergic patients with previous macrolide use, recommended options are whittled down to just bismuth-based quadruple therapy. “Again, it’s never the wrong answer,” Dr. Howden said.

Global Academy and this news organization are owned by the same parent company.

Dr. Howden reported disclosures related to Horizon, Otsuka, Allergan, Aralaez, EndoStim, Ironwood, Pfizer, and SynteractHCR.

Recent clinical guidelines have expanded not only the pool of patients who should be tested for Helicobacter pylori infection, but also the number of first-line treatment strategies clinicians should consider.

The American College of Gastroenterology guidelines from 2007 recommended just two treatments: clarithromycin-based triple therapy or bismuth-based quadruple therapy.

The 2017 update to ACG guidelines adds five additional recommended treatment possibilities, not all of which have been well studied in U.S. clinical practice, Colin W. Howden, MD, AGAF, said in a presentation at the inaugural Perspectives in Digestive Diseases meeting held by Global Academy for Medical Education.

“There are a variety of options, and unfortunately for us as practitioners, antibiotic sensitivity testing is not routinely or easily available in contemporary U.S. practice,” said Dr. Howden, professor of medicine–gastroenterology at the University of Tennessee Health Sciences Center, Memphis.

Dr. Howden, a coauthor of the latest ACG guidelines, said asking two pointed questions outlined in the document can help simplify the treatment decision:

• Is there a penicillin allergy?
• Has there been previous macrolide exposure?

“The ideal situation is that the patient is not penicillin allergic, and they’ve never had a macrolide before,” Dr. Howden said. In that case, bismuth-based quadruple therapy would be an appropriate choice.

“Bismuth quadruple therapy is never the wrong answer,” he added.

Clarithromycin-based triple therapy might be considered, according to Dr. Howden, if the local rate of resistance to H. pylori is known to be low.

Bismuth-based quadruple therapy consists of a proton pump inhibitor (PPI) or H₂ blocker, bismuth, tetracycline, and metronidazole for 10-14 days, while clarithromycin triple therapy consists of a PPI, clarithromycin, and amoxicillin or metronidazole for 10-14 days.

Several other options recently added to the guidelines have been tried in this scenario, he noted, including concomitant therapy, which consists of a PPI, clarithromycin, amoxicillin, and metronidazole for 10-14 days.

If there has been previous macrolide use but the patient is not penicillin allergic, bismuth quadruple therapy is again recommended, Dr. Howden said, and an additional approach might be the introduction of a levofloxacin-based regimen, as outlined in the guidelines.

Conversely, if there has been no previous macrolide use but the patient is confirmed to be penicillin allergic, the current guideline-recommended options are limited to bismuth quadruple therapy, or clarithromycin triple therapy with metronidazole instead of amoxicillin, Dr. Howden said at the meeting.

Finally, for penicillin-allergic patients with previous macrolide use, recommended options are whittled down to just bismuth-based quadruple therapy. “Again, it’s never the wrong answer,” Dr. Howden said.

Global Academy and this news organization are owned by the same parent company.

Dr. Howden reported disclosures related to Horizon, Otsuka, Allergan, Aralaez, EndoStim, Ironwood, Pfizer, and SynteractHCR.

Recent clinical guidelines have expanded not only the pool of patients who should be tested for Helicobacter pylori infection, but also the number of first-line treatment strategies clinicians should consider.

The American College of Gastroenterology guidelines from 2007 recommended just two treatments: clarithromycin-based triple therapy or bismuth-based quadruple therapy.

The 2017 update to ACG guidelines adds five additional recommended treatment possibilities, not all of which have been well studied in U.S. clinical practice, Colin W. Howden, MD, AGAF, said in a presentation at the inaugural Perspectives in Digestive Diseases meeting held by Global Academy for Medical Education.

“There are a variety of options, and unfortunately for us as practitioners, antibiotic sensitivity testing is not routinely or easily available in contemporary U.S. practice,” said Dr. Howden, professor of medicine–gastroenterology at the University of Tennessee Health Sciences Center, Memphis.

Dr. Howden, a coauthor of the latest ACG guidelines, said asking two pointed questions outlined in the document can help simplify the treatment decision:

• Is there a penicillin allergy?
• Has there been previous macrolide exposure?

“The ideal situation is that the patient is not penicillin allergic, and they’ve never had a macrolide before,” Dr. Howden said. In that case, bismuth-based quadruple therapy would be an appropriate choice.

“Bismuth quadruple therapy is never the wrong answer,” he added.

Clarithromycin-based triple therapy might be considered, according to Dr. Howden, if the local rate of resistance to H. pylori is known to be low.

Bismuth-based quadruple therapy consists of a proton pump inhibitor (PPI) or H₂ blocker, bismuth, tetracycline, and metronidazole for 10-14 days, while clarithromycin triple therapy consists of a PPI, clarithromycin, and amoxicillin or metronidazole for 10-14 days.

Several other options recently added to the guidelines have been tried in this scenario, he noted, including concomitant therapy, which consists of a PPI, clarithromycin, amoxicillin, and metronidazole for 10-14 days.

If there has been previous macrolide use but the patient is not penicillin allergic, bismuth quadruple therapy is again recommended, Dr. Howden said, and an additional approach might be the introduction of a levofloxacin-based regimen, as outlined in the guidelines.

Conversely, if there has been no previous macrolide use but the patient is confirmed to be penicillin allergic, the current guideline-recommended options are limited to bismuth quadruple therapy, or clarithromycin triple therapy with metronidazole instead of amoxicillin, Dr. Howden said at the meeting.

Finally, for penicillin-allergic patients with previous macrolide use, recommended options are whittled down to just bismuth-based quadruple therapy. “Again, it’s never the wrong answer,” Dr. Howden said.

Global Academy and this news organization are owned by the same parent company.

Dr. Howden reported disclosures related to Horizon, Otsuka, Allergan, Aralaez, EndoStim, Ironwood, Pfizer, and SynteractHCR.

SALT LAKE CITY – Both male and female recipients of childhood hematopoietic stem cell transplantation (HSCT) were very likely to have severely decreased fertility potential, even in the setting of preserved puberty, according to a recent study of adolescent and young adult HSCT recipients.

A reduced intensity conditioning regimen did not protect this cohort from decreased fertility, a finding that surprised the study’s lead author.

“We had hypothesized that, as compared to myeloablative conditioning, reduced intensity conditioning in children who received HSCT would lower the risk of infertility and lessen gonadal failure,” said Helen Oquendo del Toro, MD. In fact, Dr. Oquendo del Toro and her collaborators found that more than 90% of semen samples available for analysis had results that indicated infertility or severely impaired fertility, regardless of the type of pretransplant conditioning the patient had received.

The study highlights the need for fertility preservation when possible before HSCT, and makes clear that “normal puberty does not equate to normal fertility,” said Dr. Oquendo del Toro, of Cincinnati Children’s Hospital Medical Center.

Dr. Oquendo del Toro presented results of an observational cohort study of late effects of HSCT that included individuals aged 1-40 years old who received a single HSCT at, or after, 1 year of age.

Twenty-one males in the study had semen available for analysis. Of the 10 males who received myeloablative conditioning (MAC), 8 had azoospermia, and 2 more had oligoteratospermia (low sperm count with abnormal morphology). For the 11 males who received reduced intensity conditioning (RIC), eight had azoospermia, two had semen samples that showed oligoteratospermia, and one had a normal semen analysis.

The median age at transplant for these males was 14.5 years, and patients were a median of 19 years old at follow-up, Dr. Oquendo del Toro said at the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.

koakes@mdedge.com

SOURCE: Oquendo del Toro H et al. The 2018 BMT Tandem Meetings, Abstract 88.

SALT LAKE CITY – Both male and female recipients of childhood hematopoietic stem cell transplantation (HSCT) were very likely to have severely decreased fertility potential, even in the setting of preserved puberty, according to a recent study of adolescent and young adult HSCT recipients.

A reduced intensity conditioning regimen did not protect this cohort from decreased fertility, a finding that surprised the study’s lead author.

“We had hypothesized that, as compared to myeloablative conditioning, reduced intensity conditioning in children who received HSCT would lower the risk of infertility and lessen gonadal failure,” said Helen Oquendo del Toro, MD. In fact, Dr. Oquendo del Toro and her collaborators found that more than 90% of semen samples available for analysis had results that indicated infertility or severely impaired fertility, regardless of the type of pretransplant conditioning the patient had received.

The study highlights the need for fertility preservation when possible before HSCT, and makes clear that “normal puberty does not equate to normal fertility,” said Dr. Oquendo del Toro, of Cincinnati Children’s Hospital Medical Center.

Dr. Oquendo del Toro presented results of an observational cohort study of late effects of HSCT that included individuals aged 1-40 years old who received a single HSCT at, or after, 1 year of age.

Twenty-one males in the study had semen available for analysis. Of the 10 males who received myeloablative conditioning (MAC), 8 had azoospermia, and 2 more had oligoteratospermia (low sperm count with abnormal morphology). For the 11 males who received reduced intensity conditioning (RIC), eight had azoospermia, two had semen samples that showed oligoteratospermia, and one had a normal semen analysis.

The median age at transplant for these males was 14.5 years, and patients were a median of 19 years old at follow-up, Dr. Oquendo del Toro said at the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.

koakes@mdedge.com

SOURCE: Oquendo del Toro H et al. The 2018 BMT Tandem Meetings, Abstract 88.

SALT LAKE CITY – Both male and female recipients of childhood hematopoietic stem cell transplantation (HSCT) were very likely to have severely decreased fertility potential, even in the setting of preserved puberty, according to a recent study of adolescent and young adult HSCT recipients.

A reduced intensity conditioning regimen did not protect this cohort from decreased fertility, a finding that surprised the study’s lead author.

“We had hypothesized that, as compared to myeloablative conditioning, reduced intensity conditioning in children who received HSCT would lower the risk of infertility and lessen gonadal failure,” said Helen Oquendo del Toro, MD. In fact, Dr. Oquendo del Toro and her collaborators found that more than 90% of semen samples available for analysis had results that indicated infertility or severely impaired fertility, regardless of the type of pretransplant conditioning the patient had received.

The study highlights the need for fertility preservation when possible before HSCT, and makes clear that “normal puberty does not equate to normal fertility,” said Dr. Oquendo del Toro, of Cincinnati Children’s Hospital Medical Center.

Dr. Oquendo del Toro presented results of an observational cohort study of late effects of HSCT that included individuals aged 1-40 years old who received a single HSCT at, or after, 1 year of age.

Twenty-one males in the study had semen available for analysis. Of the 10 males who received myeloablative conditioning (MAC), 8 had azoospermia, and 2 more had oligoteratospermia (low sperm count with abnormal morphology). For the 11 males who received reduced intensity conditioning (RIC), eight had azoospermia, two had semen samples that showed oligoteratospermia, and one had a normal semen analysis.

The median age at transplant for these males was 14.5 years, and patients were a median of 19 years old at follow-up, Dr. Oquendo del Toro said at the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.

koakes@mdedge.com

SOURCE: Oquendo del Toro H et al. The 2018 BMT Tandem Meetings, Abstract 88.