Disparities in Gastroenterology: Health Equity Begins with Cancer Screenings

Unmitigated health disparities remain a persistent challenge in gastroenterology. Black Americans are substantially more likely to receive a diagnosis of colorectal cancer (CRC) than their White counterparts and are even more likely to die from the disease.^1,2 In large part, these disparities are driven by low CRC screening rates among Black patients.^1,3 Screening rates are higher among White patients due to myriad factors, including greater overall healthcare access and a homogenous physician workforce with little experience treating vulnerable populations.^2,3

The COVID-19 crisis unmasked entrenched inequities in the United States healthcare system and added urgency to health equity research.^2,4 Efforts to address deficiencies in current gastroenterology practice must include policy-driven research, healthcare outreach, and medical training programs with formal health equity modules.

Since 2008, when the overall CRC screening uptake rate in the US was estimated at 53.1%, gastroenterologist groups have prioritized the expansion of screening infrastucture.³ Widespread screening promotion campaigns and the use of CRC screening as a quality metric for insurance providers were among recent initiatives. The passage of the Affordable Care Act in 2010 also allowed for substantial improvements in CRC screening accessibility and infrastructure.

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While overall screening uptake has improved over time, disparities persist among minority groups. Data collected by the Behavioral Risk Factor Surveillance System indicate that screening uptake among White Americans increased from 63.9% to 70.4% between 2008 and 2016. Among Black patients, these rates were just 60.6% and 66.4%, respectively; a smaller improvement than that reported among White patients, and a significantly lower 2016 screening rate. The lowest observed rates were among Hispanic/Latinx patients: 44.7% in 2008 and 53.4% in 2016. American Indian and Alaskan Native populations also experienced a smaller percentage increase than White patients, with their 2016 screening rates remaining under 60.0%.³ These findings emphasize the uneven efficacy of intervention programs; a “one size fits all” approach will not have comparable benefits across groups. Instead, investment in tailored strategies is essential to reducing morbidity and mortality in gastroenterology.

The Association of Black Gastroenterologists and Hepatologists (AGBH), established in February 2021, proposes addressing inequities within the workforce. “[A] more proportionate representation of the Black community [among physicians],” AGBH members write, allows for “racial concordance” with treated populations.² Prior research underscores the validity of this approach. Study data published in 2018 found that Black men were more likely to consent to CRC screenings when proposed by a physician of the same race. Additional studies indicate that physicians from underrepresented backgrounds are more likely to provide healthcare for underserved patients.²

Beyond addressing workforce constituents, gastroenterology curriculum must incorporate race and bias training, as physicians noted in a 2021 review in Gastroenterology. The current structure of gastroenterology fellowship provides “very few learning environments” for trainees that address the variability in care outcomes among patients in minority groups.⁵ Cultural competency is typically an informal component of physician training, rather than a cornerstone of care quality.

Formal health equity modules are the first step towards addressing the unique needs of marginalized populations. The American Gastroenterology Association Institute promoted further curriculum tools, including an annual case conference focused on health equity, the development of formal online resources for students, and an annual journal club focused on equity research. Further, quality improvement programs focused on outcomes of patients in minority groups will embed equity into the formal clinic appraisal process.⁵

In the wake of incalculable losses following the pandemic, renewed emphasis has been placed on health equity and care accessibility. In gastroenterology, where inequities persist and contribute to excess mortality, health professionals and policy makers alike must invest in screening programs that address disparities. Evidence-based interventions known to increase screening uptake include direct patient outreach from staff, enhanced equity training for physicians, and a more representative workforce.^2,3,5 Taken together, these factors are valuable tools in the fight against care inequities.

References

1. American Cancer Society. Colorectal cancer facts & figures 2017-2019. Updated 2017. Accessed June 30,^, 2021. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2017-2019.pdf
2. White PM, Iroku U, Carr RM, et al. Advancing health equity: the Association of Black Gastroenterologists and Hepatologists. Nat Rev Gastroenterol Hepatol. Published online May 10, 2021. doi: 10.1038/s41575-021-00464-y
3. Demb J, Gupta S. Racial and ethnic disparities in colorectal cancer screening pose persistent challenges to health equity. Clin Gastroenterol Hepatol. 2020;18(8):1691-1693. doi: 10.1016/j.cgh.2019.11.042
4. Webb Hooper M, Nápoles AM, Pérez-Stable EJ. COVID-19 and racial/ethnic disparities. JAMA. 2020;323(24);2466–2467.
5. Lee-Allen J, Shah BJ. How to incorporate health equity training into gastroenterology and hepatology fellowships. Gastroenterol. 2021;160(6):1924-1928. doi: 10.1053/j.gastro.2021.03.018

This article originally appeared on Gastroenterology Advisor