CRC is the third most frequently diagnosed cancer and the second leading cause of cancer related deaths in the United States. In 2008, 148,810 new diagnoses of CRC were predicted with an estimated 49,960 deaths from the disease'. The incidence of CRC increases with age, with 24 cases annually per 100,000 persons between the ages of 45 and 49 years, and 48 cases annually per 100,000 persons between the ages of 50 and 54. This corresponds to 8% of all CRCs occurring in those under age 50(7). AAs have a higher incidence of CRC, and are also diagnosed at an eariier age. The overall incidence of CRC in AAs is 12.3% higher than that of whites(7). The median age of onset is 6 years younger for AAs (67 vs 73)(8). The California Cancer Registry found that 10.6% of AAs with CRC were under the age of 50, compared to only 5.5% of whites. The incidence of CRC at age 50 in this registry was 56.5 in blacks and 33.2 in whites(9). Data collected from 67 endoscopy centers over a period of two years found the incidence of advanced neoplasia in AAs aged 40-49 to be 6.2% as compared to 4.2% in whites. In this study, blacks age 40-49 had a higher incidence of advanced neoplasia than whites age 50-59. CRC mortality can be reduced by a simple screening test. Multiple studies have documented the effectiveness of FOBT with reductions ranging from 15 - 33%(10-12) Testing for occult blood is simple, low cost, and associated with minimal harms. FOBT is now performed using an immunohistochemical method to detect occult blood in stool, so that the test is specific for human hemoglobin. This confers a significant advantage, as pre-testing dietary restrictions are no longer necessary. The sensitivity of FOBT performed via an immunohistochemical method for detecting CRC has been estimated from 65.8%(13) - 94.1%(14). Based on other population-based studies, a positive FOBT will befound among 4-7% of asymptomatic individuals. Of those with a positive FOBT, approximately 10% will have CRC at the time of follow-up colonoscopy. A number of different organizations have published guidelines for CRC screening. Current consensus guidelines recommend screening beginning at age 50 for average risk individuals, regardless of race(2). The consensus statement acknowledged that there are well-documented racial disparities in CRC, but opted to delay making specific recommendations as the collaborating institutions closely monitor research in the area. Following an extensive review of CRC racial disparities, the American College of Gastroenterology recommended initiating CRC screening among AAs at age 45. This was given a Grade 2C (weak) recommendation level, however, as more trials are needed(3). The three major studies that have shown an improvement in CRC mortality via CRC screening do not stratify results by race, nor do they identify the race of the participants. However, these three studies were performed in Denmark'(11), the United Kingdom(10) , and Minnesota (12), which have black populations of <1%, 2%, and 4% respectively. We can therefore assume that AAs have been grossly underrepresented in these major trials. The optimum time to begin CRC screening for AAs is cleariy an area of continued debate. The presence of racial health disparities is not in question;the increased prevalence, eariier age of diagnosis, and poorer prognosis of CRC among AAs is well documented and well accepted. While multiple studies have demonstrated the increased risk of advanced neoplasia among AAs under age 50, no studies have specifically examined AAs who would not be screened according to the current consensus guidelines. Hesitancy to change current guidelines is based on the lack of direct evidence that eariier screening will benefit African Americans, as well as a fear of complicating the guidelines. This project aims to lay the foundation for further study that may provide evidence that asymptomatic AAs age 40-49, who are not eligible for CRC screening under the current consensus guidelines, would benefit from CRC screening to a similar or greater extent than whites age 50-59, who are currently eligible. Multiple studies have demonstrated lower rates of participation in research studies and clinical trials by AAs(4,15), and even demonstrated decreasing participation by AAs in recent years. Several explanations for this disparity have been offered. Past instances of discrimination and abuse of trust likely continue to affect provider-patient relationship, and may lead to concerns about experimental research and the motives of investigators. Other obstacles include cultural barriers, provider bias, and socioeconomic factors. CBPR is a promising methodology to engage minorities in the research process and help combat these barriers. The already existing strength ofthe well-established DSNCC offers a substantial resource to overcome these obstacles and engage AAs in this clinical trial. This proposal will demonstrate how participation in clinical research can make a difference within a community by working towards reducing current health disparities.
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