Colorectal cancer is the second leading cause of cancer death in the United States, estimated to account for more than 53,000 deaths per year. It is also the third most common type of cancer with an estimated 152,810 new cases expected in 2024, predominantly in the younger population under 50 years old. Despite its prevalence, rates of incidence and mortality for colorectal cancer has been decreasing, due in part to the availability of screening tests which allows for early detection and treatment.
Yet this progress is not consistent, with some population groups having a disproportionally higher risk of developing or dying from colorectal cancer. This risk stems from health inequities that impede access to care that can prevent, detect, and manage the disease, leading to worse health outcomes and higher costs of care.
“Health inequities are not new and have been highly prevalent among those with cancer, including colorectal cancer,” said Dr. Neema Stephens, national medical director for health equity for The Cigna Group. “Extra efforts are needed to help ensure underserved and historically marginalized communities can access the proper prevention and care services they need.”
Colorectal cancer disparities among Americans
Colorectal cancer diagnosis and mortality rates differ widely across racial and ethnic groups, with American Indians/Alaska Natives and African Americans/Blacks most at risk of developing colorectal cancer and most likely to die of the disease.
Incidence rates of colorectal cancer, by race/ethnicity (per 100,000 people)
Mortality rates of colorectal cancer, by race/ethnicity (per 100,000 people)
Source: The American Cancer Society
American Indians/Alaska Natives and African Americans/Blacks are also more likely to develop colorectal cancer under the age of 50 than other adults.
Incidence rates of early onset colorectal cancer (among U.S. adults ages 40 to 49), by race/ethnicity (per 100,000 people)
Source: North American Association of Central Cancer Registries
Researchers have also found disparities in colorectal cancer screening. While African Americans/Blacks, who had historically lower rates of colorectal cancer screening, are now screened at roughly the same rate as non-Hispanic whites, American Indians/Alaska Natives, Asians and Pacific Islanders, and Hispanics/Latinos have significantly lower rates of screening. These populations report experiencing more challenges in access to care, as well as increased social needs, according to Evernorth’s research.
Rates of colorectal cancer screening of U.S. adults, by race/ethnicity (%)
Source: The American Cancer Society
Social factors have been linked to higher rates of colorectal cancer and lower survival rates, as well as lower participation in regular colorectal cancer screenings. In fact, health inequities are often exacerbated by social factors. Limited access to nutritious food, social isolation, health literacy, and access to preventive care can create challenges to securing timely and early screening. “While the type and level of social needs can vary from person to person, each one of these social determinants of health can create obstacles to effective colorectal cancer prevention, diagnosis, and treatment,” Dr. Stephens said.
Awareness and screenings can save lives
Driving awareness of the value of colorectal cancer screenings and increasing access to them among underserved populations are key to reducing colorectal cancer disparities.
“Health plans can help increase colorectal cancer awareness through targeted member education campaigns that highlight risk factors and potential signs, as well as the importance of screening and prevention,” said Dr. Bhuvana Sagar, an oncologist and the senior medical principal who leads clinical innovation at Evernorth. “This is crucial because those with severe health disparities are more likely to be diagnosed with colorectal cancer at later stages of the illness,” she said, noting that African American/Black patients, in particular, are not only more likely to have colorectal cancer at a younger age than their white counterparts, but are also the most likely to be diagnosed after the cancer had metastasized and spread to other parts of the body.
Potential signs of colorectal cancer include changes in bowel patterns, rectal bleeding, anemia, and unexplainable abdominal pain or weight loss. Dr. Sagar says people experiencing any of these symptoms should immediately seek care. However, many people diagnosed with the disease may not show symptoms right away, which is why screenings are so important.
Adults 45 and older should have regular colorectal cancer screenings. Younger adults should talk to their doctor about their potential risk - especially if they have a family history of cancer, a personal history of inflammatory bowel disease, or experience any of the potential signs - and ask when they should begin screening. Dr. Sagar suggests that health plans should encourage members to have these conversations with their doctor during their next regular visit. Recommended cancer screenings are covered at no cost to the member as per the Affordable Care Act. Detecting cancer at an earlier stage can save lives and improve outcomes, as well as lead to lower total cost of care compared to an advanced stage at diagnosis.
Many people diagnosed with the disease may not show symptoms right away, which is why screenings are so important.
Adults 45 and older should have regular colorectal cancer screenings. Younger adults should talk to their doctor about their potential risk and ask when they should begin screening.
Dr. Sagar added that health plans should also promote healthy lifestyle habits that can help people reduce their risk of colorectal cancer. These include maintaining a healthy weight, engaging in physical activity, avoiding tobacco, and avoiding moderate or heavy alcohol use. National organizations such as the Centers for Disease Control and Prevention (CDC) offer educational resources that health plans can use in their campaigns.
Addressing social determinants of health
In addition to raising awareness, it is crucial for health plans to proactively address the non-clinical factors that contribute to health outcomes. “Through the provision of culturally and linguistically appropriate care, we can become better health advocates and promote health literacy,” Dr. Stephens said. She noted that greater health literacy has been linked to participation in recommended colorectal cancer screenings.
Many health plans can work with local care providers, community health centers, patient advocacy groups, and other stakeholders to set up specialized programs in underserved communities that can help overcome social barriers and foster health equity for colorectal cancer. These programs can offer referrals to community resources such as translation assistance services and rideshare programs for those who need transportation to and from a colonoscopy.
Community partnerships and trusted voices are also important, Dr. Stephens said. She cited as an example the Health Advocates In-Reach and Research (HAIR) initiative by the University of Maryland's Center for Health Equity, in which neighborhood barbers and hair stylists are actively promoting colorectal cancer screenings among African American/Black men and women. This program is financially supported by a grant from The Cigna Group Foundation.
“The first step to addressing social determinants of health is to examine data to identify potential risk factors, as well as any barriers to care members may face,” Dr. Stephens said. She added that health plans can use assessment tools, such as the Social Vulnerability Index and the Evernorth Social Determinants Index (ESDI), to identify areas of greater social need among their population. “Those insights will guide health plans on where to focus their education campaigns and other interventions for maximal impact,” she said.
