Highlighting the Disparities in Risk Factors for Colorectal Cancer Among African Americans
By Alfa Lafleur, APRN
Late actor Chadwick Boseman
In 2020, according to the American Cancer Society, an estimated 150,000 will be diagnosed with colorectal cancer (CRC) (1). These rates have led to increased attention being paid to the CRC burden, especially since rates are increasing in younger individuals. With the recent death of actor Chadwick Boseman, researchers and the media have aimed their focus in studying and highlighting the disparities affecting African Americans. The highest incidence and mortality rates are found in the African American population. Nobody knows the specific contributing factors that led to Chadwick Boseman’s diagnosis at the young age of 39, but the traditional risk factors need to be readdressed, given the higher rates.
Risk factors are broken down into non-modifiable, meaning they cannot be changed, and modifiable, which means you can take measures to change them. Although race, like age, is a non-modifiable risk factor, it is not included in the broad screening recommendations, despite the statistics that demonstrate the disparities. Other non-modifiable risk factors specific to CRC include: personal history of colorectal polyps or inflammatory bowel disease such as Crohn’s disease or ulcerative colitis; family history of colon polyps or CRC; and genetic syndromes such as familial adenomatous polyposis and Lynch syndrome. When compared to white Americans, African Americans also see high rates of inflammatory bowel disease and are less likely to know or communicate personal or family history of polyps, adenomas, CRC or other genetic conditions. This leads to decreased screening rates and, ultimately, worse outcomes.
Modifiable risk factors shown to have an association with CRC include type II diabetes, obesity, unhealthy diet, lack of physical activity, cigarette smoking and excess alcohol intake. Studies have implicated insulin resistance, including the fact that elevated insulin and insulin-like growth factor stimulate colorectal tumor cell growth. The risk for and high prevalence of insulin resistance, followed by overt type 2 diabetes, is high in African Americans. Excess body weight is associated with several diseases, including CRC. Study results have shown that obese adults are at approximately 20% greater risk of developing CRC, compared with those of normal weight. Among African- American adults, close to 48% are considered clinically obese, including 37% of men and 56% of women, compared to 32% of whites (2).
Like obesity, diet is another important modifiable risk factor. A 2020 World Health Organization report reviewed the evidence relating consuming processed meat with CRC (3). Processed meats have been preserved by smoking, salting, curing or adding preservatives, and include deli meats, corned beef, hotdogs, pepperoni, bacon, and deli meats. The chemicals in these meats can damage cells in the colon and rectum, increasing the risk of CRC. A cancer prevention study, looking at the relationship between meat intake and cancer, found that African American men reported consuming more processed meats than white men (129 grams vs. 92 grams per week) (4).
Observational epidemiological evidence shows a CRC risk reduction associated with regular physical activity is estimated to be 25-30%. (5). The effect that physical activity has on the formation of the cancer cells are possibly influenced by the levels of physical activity, including type, intensity, frequency and length of activity.
Cigarette smoking introduces toxins and chemicals into the body that damage DNA and cause mutation of cells. Both length of time smoked and amount of cigarettes smoked, play a major role in increased risk. According to the CDC, African Americans smoke fewer cigarettes and start smoking at an older age than white Americans, however, they are more likely to die from smoking-related diseases than whites. Additionally, African American children, adolescents, and adults were more likely to be exposed to second-hand smoke than any other racial group (6). Heavy alcohol abuse, specifically intake in excess of 1 serving of alcohol per day, increases CRC risk. Individuals that drink 2–3 alcoholic beverages a day have a 20% increased risk of developing CRC, while for those who consume greater than three drinks, this risk increases to 40%. The association is stronger in men, probably due to hormone-related variations in alcohol metabolism. Men are also more likely to drink larger quantities and under-report how much they drink. The most recent National Survey on Drug Use and Health found that the rate of heavy drinking among African Americans is 4.3%, in comparison to white Americans at 7.2%. Rates of binge drinking and alcohol use disorders were also found to be lower in African Americans (7).
Based on the proven, higher incidence of CRC in the African American community, researchers are bringing more awareness about these risk factors. Through understanding of the risk factors, in both health care providers and the community, action can be taken towards prevention. We can all take responsibility to educate and encourage others to learn about their non-modifiable and modifiable risk factors. Have discussions with family members regarding who has been diagnosed with advanced polyps or CRC, especially first and second degree relatives. Sharing this information with your provider helps them to facilitate the appropriate resources and screening.
Additionally, awareness must be raised that CRC is preventable when modifiable risk factors are recognized and controlled though lifestyle changes. Those living with diabetes must be aware of their blood glucose levels and take medications as prescribed to manage the disease. Obesity, unhealthy diet, and lack of physical activity are linked. The essential factor in weight loss is the motivation to eat properly and exercise. Consuming a well balanced diet, that includes lean meats, fruits, vegetables and whole grains, in addition to 30-60 minutes of moderate to vigorous activity daily, can help to reduce the risk of development of CRC.
By raising awareness and calling more attention to what is already known about CRC risk factors, we can gain the momentum needed to overcome the disparity in the African American community.
Alfa Lafleur, APRN is board-certified as a Family Nurse Practitioner and has over 15 years of experience in healthcare. She holds 2 undergraduate degrees in Psychology and Nursing from Curry College, a Master of Science in Nursing degree from LaSalle University and a post-graduate nurse practitioner certification from the University of Massachusetts-Boston.
She has a passion for partnering with her patients to optimize health and wellness, and works diligently to improve healthcare access and equity to vulnerable and underserved populations.
Contact: alfa.lafleur@outlook.com
Sources
https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2020-2022.pdf
http://stateofobesity.org
https://publications.iarc.fr/586
https://cebp.aacrjournals.org/content/cebp/15/2/211.full.pdf
https://bmccancer.biomedcentral.com/articles/10.1186/s12885-017-3970-5
https://www.cdc.gov/tobacco/disparities/african-americans/index.htm
https://www.samhsa.gov/data/report/2018-nsduh-detailed-tables