But, as rates began falling in the 1980′s for both blacks and white patients, decreases for whites were substantially greater than those for blacks.  Between 1985 and 2008, mortality rates for whites with colorectal cancer fell 40 percent, while black rates declined by less than 20 percent.

The decrease in black death rates was higher than those for whites at every stage at diagnosis, but strikingly different when cancer had spread to distant sites.   For whites whose colon or rectal cancer was first found at stage IV, death rates fell by more than 30 percent, while black rates declined by less than 5 percent.

Over time, five year survival after regional and distant diagnoses grew for white patients but remained essentially unchanged for blacks.

Anthony Robbins, MD, PhD and his team from the American Cancer Society analyzed information from the Surveillance, Epidemiology, and End Results (SEER) Program looking for changes in colorectal cancer mortality rates by race and stage at diagnosis from 1985 through 2008.  They found that 60 percent of the disparities between black and white rates were due to late stage diagnosis.

They reported decreases in colorectal cancer death rates between 1985-1987 to 2006-2008 by stage:

Once cancer had spread regionally to lymph nodes or to distant organs, five year survival was lower in blacks than whites. Survival didn’t change significantly over time for blacks over time for regional disease, although there was a small increase that began in 2002 for metastatic cancer.

Percentage of patients living five years or more after diagnosis:

In discussing their observations, Dr. Robbins and his group looked for possible reasons for the disparities that continued even as death rates dropped and survival improved.  Among factors they considered were:

• Less screening for blacks than whites.  Although screening rates have improved for both blacks and whites, colorectal screening for blacks continues to lag behind.
• Differences in treatment for both colon and rectal cancer.  Blacks were less likely to receive adjuvant chemotherapy for stage III colon cancer or surgery for rectal cancer.  They also were treated less often at high volume, high quality cancer centers and got modern chemotherapy less often.
• Although there may be biological reasons for disparities, lack of access to prevention and quality care is more likely, Robbins writes.  In clinical trials where all patients had the same treatment, there were no differences in outcomes between blacks and whites.

Dr. Robbins and colleagues concluded,

In conclusion, colorectal cancer death rates have decreased for each stage of the disease in both whites and blacks since 1985, although for every stage, the decreases were smaller for blacks, especially for distant-stage disease. In the most recent time period, disparities in regional-stage and distant-stage mortality rates accounted for approximately 20% and 60% of the overall black-white disparity, respectively. Efforts to reverse the overall racial disparity in CRC mortality must target late-stage disease.

In an editorial accompanying the article, Electra Paskett, PhD, from the Ohio State University wrote,

In summary, disparities in colorectal cancer outcomes exist, and we know why. It is time to start addressing these disparities so that good health can be something everyone can experience.

Dr. Paskette stressed the importance of:

• Improving screening rates among blacks by making sure insurance covers screening for everyone and that health providers have systems in place and incentives to recommend screening to their patients.
• Making sure that there are not financial barriers to prompt, quality treatment when cancer is diagnosed.
• Using patient navigators to improve use of preventive screening and ensure access to prompt quality care.
• Enrolling more minority patients in clinical trials, including using families and communities to improve accrual.

SOURCES:  Robbins et al., Journal of Clinical Oncology, Early Release, December 19, 2011.

Paskett, Journal of Clinical Oncology, Early Release, December 19, 2011.

What Can Advocates Do?

Patient advocates can play an important role in narrowing the gap in colorectal cancer death rates between blacks and whites in the United States. They can:

• Work to make sure that the full range of colorectal cancer screening options are available to everyone without discrimination due to insurance status, income, race, ethnicity, or the community where they live.
• Insist that every American have full access to insurance coverage and a means to pay for quality evidence-based cancer care.
• Raise awareness of the value of screening to prevent colorectal cancer in ways that are meaningful to minority communities.
• Advocate for funding and programs to provide patient navigation.
• As research advocates, increase enrollment of minorities in cancer clinical trials.

Although many of the provisions of the new law are phased in to take effect gradually until the entire law is implemented in 2018, some benefits will be available immediately.

Highlights of the provisions that will benefit individuals people facing cancer treatment include: prohibiting insurance companies from dropping patients who become sick; eliminating lifetime and annual limits on coverage; prohibiting insurance companies from denying coverage because of pre-existing conditions; and limits on on out-of-pocket expenses.

You can review a chart developed by C3 with key issues affecting colorectal cancer prevention and treatment that are part of the health care reform legislation.

While historic, enactment of this new law is just one step in an ongoing process.  Even after all the provisions in the new law take effect in 2018, many Americans may be newly insured but will still fail to receive the right treatment at the right time.  The Colorectal Cancer Coalition continues to support research to help develop new treatments and to support efforts to increase awareness about the importance of early detection and screening.

BENEFITS IF YOU HAVE BEEN DIAGNOSED WITH COLORECTAL CANCER:

• Beginning immediately, health insurance plans cannot drop you or reduce your benefits just because you become sick, a process called rescission.
• After January 1, 2014, insurance plans will not be able to deny coverage or charge higher premiums if you have a pre-existing condition.  Until that time, people with pre-existing conditions will be able to find affordable insurance in special high-risk pools supported with federal funds.  For people with inherited colorectal cancer who worry about testing for a genetic condition, the law specifically includes genetic information among the health conditions for which there cannot be discrimination.
• Six months after the the law is enacted, insurance companies can no longer place lifetime limits on healthcare coverage, nor can they impose restrictive annual limits.  In 2014, all group and individual plans must eliminate annual limits.  Even if you need expensive cancer care, you will no longer need to worry about your insurance refusing to meet those costs.
• Depending on your income, there will be limits on the amount of money you need to pay out-of-pocket for health care for you and for your family each year.
• In 2014, uninsured people will have access to several new options including higher income limits for Medicaid and participation in an American Health Benefit Exchange.  The exchanges will clearly outline costs and benefits of each health care policy so consumers can make  informed choices about care.  Subsidies will be available to keep costs affordable.

BENEFITS IF YOU WANT TO PREVENT COLORECTAL CANCER:

• If you are privately insured through your employer or the insurance exchanges, preventive services are covered fully without your having to meet a deductible or pay a co-pay.
• If you are on Medicare, cost-sharing for preventive screenings will end on January 1, 2011.  In addition, there will be no additional co-payments if a polyp is discovered and has to be removed during the screening exam.  Medicare will also pay for an annual check-up.
• If you are on Medicaid preventive services will be provided at no cost.

OTHER IMPACTS ON COLORECTAL CANCER PREVENTION:

While not specifically addressing colorectal cancer, wellness and prevention of illness are addressed in several new initiatives established and funded by the law including:

• Establishment of a National Prevention, Health Promotion and Public Health Council to coordinate prevention, wellness, and public health strategies.
• Establishment of a Prevention and Public Health Fund to expand and sustain funding for prevention and public health programs, as well as task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.
• Grants to support evidence-based community prevention and wellness programs that strengthen prevention activities, reduce chronic disease rates and address health disparities, especially in rural and frontier areas.  Funding for five years beginning in FY 2010.

If you have questions about how the new law will affect you, the New York Times has an interactive site where you can look at your personal impact whether you are insured or uninsured and whether your current insurance is on your own, through an employer, or via Medicare or Medicaid.

Photo by Mara Zemgaliete

Colorectal cancer patients with early stage disease were 30 percent less likely to die from cancer and 20 percent less likely to die at all if they took aspirin regularly after their diagnosis.

Benefit was even greater for those who began taking the medicine for the first time after their diagnosis.

However, only the group whose tumors tested positive for COX-2 (cyclooxygenase2) benefited from aspirin.  

COX-2 is an enzyme that produces inflammation and pain, and aspirin blocks its activity.  About two-thirds of colon cancers express COX-2.

Data about aspirin use was collected every two years from participants in the Nurses Health Study (NHS) and the Health Professionals Follow-Up Study (HPFS). Regular aspirin use was defined as taking a 325 milligram tablet at least twice a week.

Almost 1,300 people in the two studies were diagnosed with stage I, II, or III colorectal cancer and were followed after surgery.

For all patients, regardless of COX-2 status, after a median follow-up of almost 12 years:

• 15 percent of patients who took aspirin regularly had died from colorectal cancer compared to 19 percent of non-aspirin users.
• 35 percent of aspirin-users had died from any cause compared to 39 percent of non-users.
• All patients who took aspirin were 29 percent less likely to die of colorectal cancer and 21 percent less likely to die from any cause than non-users.
• Those patients who began taking aspirin after their colorectal cancer diagnosis were 47 percent less likely to die from colorectal cancer.
• Patients with COX-2 expression in tumor tissue had a 41 percent reduction in risk of dying from colorectal cancer if they were aspirin users.
• In those without COX-2 over-expression, aspirin made no difference in risk of death from colorectal cancer.

The study team concluded,

Regular aspirin use after the diagnosis of colorectal cancer is associated with lower risk of colorectal cancer–specific and overall mortality, especially among individuals with tumors that overexpress COX-2.

Andrew Chan, MD, MPH, gastroenterologist from Massachusetts General Hospital and Harvard Medical School, who led the study said,

While previous studies by our group and others showed that aspirin and other non-steroidal anti-inflammatory drugs reduce the risk of developing colorectal cancer, this study is the among the first to show that aspirin can also improve survival in patients who have already been diagnosed with colorectal cancers. Moreover, the benefit appeared to be especially strong among patients with cancers that express COX-2. This is an important first step toward developing targeted approaches to improving patient outcomes.

Previous research has shown that aspirin reduces the risk of new colon polyps in patients recovering from early stage colon cancer.

In an editorial accompanying the JAMA article, Alfred Neugut, MD, PhD, professor of medicine and epidemiology at Columbia University, wrote,

A major recent priority in clinical oncology has been to develop biomarkers for prognosis and to predict response specific to interventions.The specificity of the response of colorectal cancers to aspirin for patients in whom tumors over-expressed Cox-2 suggests that this potential future treatment comes with its own ready-made predictive biomarker.

There is currently no commercial test on the market that tests for COX-2 in tumor tissue.  However, testing is available at academic cancer centers and research facilities.

SOURCE:  Chan et al., Aspirin Use and Survival After Diagnosis of Colorectal Cancer, Journal of the American Medical Association, Volume 302, Number 6, August 12, 2009.

What This Means for Patients

While this is good news for people with stage I, II, or III colon or rectal cancer, it is too early to make a widespread change in how colorectal cancer is treated after surgery.

Discuss using aspirin with your doctor before using it — either on a short or long term basis.

Researchers didn’t randomly assign some patients to take aspirin and others to use a placebo or sugar pill.  Instead, they asked people in the study to tell them about how much aspirin they remembered taking every two years. There was no uniform reason for taking aspirin or uniform daily or weekly dose.

Stronger, randomized studies are important before recommendations for aspirin use for all early stage patients can be made.

Aspirin can cause bleeding in the stomach and gastrointestinal tract, sometimes serious enough to be life-threatening.

Because it may interfere with blood clotting, aspirin should be avoided  before surgery, during chemo, and before a colonoscopy.  Tell your doctors if you are taking aspirin.

People come to an initial medical work-up for colon or rectal cancer from different places. They may have had a suspicious polyp or cancer found during a routine screening. They may be experienced symptoms that might be caused by colorectal cancer. Getting an accurate diagnosis is critical because treatment for colorectal cancer depends on the diagnosis. For example, treatment for colon cancer is different than treatment for rectal cancer, and treatment for cancer which has spread outside of the colon is different than treatment for cancer which is limited to the colon. Getting an accurate diagnosis can take time and many different tests. It may require surgery, and examination of surgically-removed tissue to determine whether the cancer has spread. This process can involve several health professionals including:

• The gastroenterologist who will perform a colonoscopy if it has not been already done and remove tissue for biopsy. The gastroenterologist may remove suspicious polyps for pathology or, if they are large, leave them in place for later surgical removal.
• Pathologists who will examine biopsies under the microscope to identify precancerous cells or cancer (malignancy.)
• Radiologists who will perform CT-scans or other x-ray tests to see if the cancer has spread to other parts of your body.
• A general surgeon or colorectal surgeon who will give you a physical examination and ask about your medical history, order blood tests, review reports from gastroenterologist, radiologist, and pathology, and help decide on an initial treatment plan.
• If necessary, a medical oncologist who deals with chemotherapy treatment or a radiation oncologist may be involved at this point or they may join the treatment team after surgery. Specialized surgeons may also be called in to examine you if there is a possibility that the cancer has spread beyond your colon.

Choosing a medical team is an important initial step in getting an accurate diagnosis, especially if rectal surgery is involved. Work with your medical team to make sure that your evaluation, diagnosis, and staging are done carefully and thoroughly.. Get a second opinion if there is uncertainty about issues such as what tests are necessary, if surgery is the right first step, and whether staging is accurate. A second opinion at a large cancer center, particularly a National Cancer Institute designated cancer cancer or a member of the National Comprehensive Cancer Network can be valuable even early in the diagnostic process.

• Locate an NCI Cancer Center in your state.
• Locate an NCCN Comprehensive Cancer Center

Where Can You Go for More Information?

American Cancer Society How is Colorectal Cancer Diagnosed? Cancer.Net When the Doctor Says Cancer along with a podcast can help you learn questions to ask about your cancer and its diagnosis and how to understand and manage the information you get from your doctor.

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