Black people undergoing colon cancer screening are more likely to have large precancerous polyps than are whites.
Black men had a 16 percent increased risk of polyps more than 9 millimeters (mm) in size than white men. And the difference in women was even more striking with black women having 62 percent higher odds of a 9 mm or larger polyp, according to new research.
"We've known for a long time that colon cancer is more common in blacks than in whites, and that blacks are more likely to die from colon cancer than whites," said the study's lead author, Dr. David A. Lieberman, a professor of medicine and chief of gastroenterology at Oregon Health and Science University in Portland.
"Previous studies have suggested these differences may be from a lack of access to health care, or a failure of doctors to recommend screening, or a failure of the patients to follow through on screening. But, since we took a look at patients who were already getting screening exams, access and adherence weren't an issue, and we found that black men and women had more serious polyps," Lieberman said.
The good news, he added, is that "many colon cancers can be prevented with screening," and this study shows that blacks may stand to benefit even more from colon cancer screening than whites.
Results of the study were published in the Sept. 24 issue of the Journal of the American Medical Association.
The death rates for colon cancer are about 40 percent higher in blacks than in whites, according to background information in the study. And, the disease incidence rate is between 15 percent and 23 percent higher for blacks.
The new study included 5,464 blacks and 80,061 whites who had undergone screening colonoscopy in 67 different centers across the United States. Of that group, the researchers found 422 blacks (7.7 percent) had one or more polyps that were larger than 9 mm. Among whites, almost 5,000 (6.2 percent) had one or more polyps of that size. Removing large colon polyps is important, because they are likely to turn into colon cancer.
The researchers also found that the differences persisted across different age groups. And, black women had a "strikingly" higher incidence of polyps, according to Lieberman.
"This study confirms the possibility that genetic and biological factors are playing a role in colon cancer," said Lieberman.
But, not everyone's convinced by these findings.
Dr. Otis Brawley, chief medical officer at the American Cancer Society, said the study didn't control, or compensate, for previous screening tests or socioeconomic status of the participants -- two factors he said could seriously influence the study's conclusions.
"Black women in the U.S. are more likely to have [a particular type of breast cancer called] triple-negative breast cancer than white women, and many experts have written about it and wondered if it's biology. But, if you go to Scotland, where there are few blacks, researchers wonder why poor white women are more likely to have triple-negative breast cancer," said Brawley, who added, "We tend to let our racial lens interfere with being scientific."
"It may be that colon cancer is more aggressive in blacks than in whites," he said, but the issue definitely needs more study.
No matter what your color, one thing both experts agree on is the need to have colon cancer screening beginning at age 50 for those with an average risk of the disease.
"With colon cancer screening, we have the unique opportunity to actually prevent cancer," Lieberman said.
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Virtual colonoscopies are excellent at detecting large and medium-sized polyps that can lead to colon cancer, according to the most definitive study yet published on this controversial technology. In fact, these non-invasive tests are as effective as old-fashioned colonoscopies and ready to be widely used for cancer screening, said Dr. C. Daniel Johnson, lead author of the report published in the New England Journal of Medicine.
If more people get screened because they find the virtual alternative more acceptable, that could end up saving lives, he noted. More than half of Americans who should get colon cancer screenings don't.
Insurance companies haven't been willing to pay for virtual colonoscopies, citing insufficient evidence that they work. But that could change. Medicare is reviewing data from the new study, with an eye toward re-evaluating reimbursement.
COLON CANCER
This is the second leading cause of cancer deaths in the U.S. and the third most common type of cancer. Screening for polyps is recommended at age 50, but traditional colonoscopies are so unpleasant that many people avoid them. They involve inserting a long tube topped with a miniature camera into the large intestine while the patient is sedated or under local anesthesia.
It was the largest of its kind to date, involving 2,600 men and women tested at 15 medical centers. All participants received both a virtual and a standard colonoscopy, with 99 percent of the duplicate procedures done on the same day. The virtual tests identified 90 percent of large polyps or cancers (1 centimeter or larger) detected through the traditional colonoscopies. The study confirms earlier results on a larger scale, said Dr. Abraham Dachman, professor of radiology at the University of Chicago Medical Center and a co-author of the report.
THE PROCEDURE
Virtual colonoscopies involve a CT scan of the lower body. They don't require anesthesia and are less invasive than the traditional procedures, which result in bowel perforations in 1 out of 1,000 patients.
Virtual colonoscopies are also less expensive because they're done on an outpatient basis without an anesthesiologist and pathologist present. It's common for standard colonoscopies to cost two to three times more than virtual procedures.
Patients still must take much-dreaded preparations that clean out their bowels, just as they do for traditional colonoscopies. If worrisome polyps show up, a patient will need a traditional colonoscopy so a physician can remove them. About 4 percent of all screened patients will have polyps 1 centimeter or larger, and these clearly need to be excised, Johnson said. About 12 percent of patients will have polyps 6 millimeters or larger.
At the University of Chicago, most patients stay at the hospital until they get test results. Then, if they need a traditional colonoscopy, they have the procedure the same day, without additional bowel-cleansing preparations.
CAVEATS
Smaller or flat polyps are missed more often in virtual colonoscopies, said Dr. John Affronti, a professor at Loyola University Medical Center.
In addition, even though radiation doses are half those of normal CT scans, "we still have to be concerned about the potential cumulative effects of radiation exposure," said Dr. David Lichtenstein, director of endoscopy at Boston Medical Center.
For Lichtenstein, the bottom line is "traditional colonoscopies remain the gold standard, but virtual colonoscopies are a good alternative."
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Colonoscopy performed with narrow band imaging (NBI) does not improve the miss rate of colorectal cancers compared with conventional white light examination, according to a report in the October issue of Gut. Click here to see a video of a colonoscopy.
NBI uses a light source centered at blue and green that penetrates primarily the mucosa and submucosa, making surface microvessels visible as dark structures, the authors explain. Because the density and shape of microvessels change in neoplasms, NBI could aid in the diagnosis of neoplasms.
Dr. Tonya Kaltenbach and colleagues from Stanford University School of Medicine, Palo Alto, California, investigated the neoplasm miss rate during tandem colonoscopy using NBI or white light.
A repeat colonoscopy under white light was the reference standard. "We removed any identified lesion at the time of initial detection, such that the endoscopist performed the second examination in a colon putatively cleared of lesions," the researchers explain. "Hence, we defined a 'missed' lesion as one identified during insertion or withdrawal of the second examination."
There were 37 missed neoplasms in 34 patients, the authors report, and there was no significant difference in the rate of missed lesions between the NBI (12.6%) and white light groups (12.1%).
The characteristics of the missed neoplasms did not differ between the NBI and white light examinations, the report indicates.
The neoplasm detection rates did not differ between the NBI and white light colonoscopy exams, the investigators say. The overall adenoma detection rate was 49%.
In a multivariate model, lesion size, morphology, and quality of bowel preparation had no significant influence on the association of NBI with neoplasm miss and detection rates.
"We did not find NBI to significantly influence the likelihood of missing or detecting a colorectal neoplasm compared to white light," the researchers conclude. "The 12% miss rate observed in our study, however, is approximately half of that reported in a recent systematic review of the published literature on adenoma miss rate determined by tandem colonoscopy."
"Future larger, comparative studies of the diagnostic characteristics of specific colonoscope features such as wide angle of view or high definition, CT colonography and other candidate screening modalities are of interest to advance the efficacy of colorectal cancer prevention," they add.
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