Disparities in Endoscopy Use for Colorectal Cancer Screening in the United States

Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Drive, 10th Floor, Chicago, IL, USA, .
Digestive Diseases and Sciences (Impact Factor: 2.61). 11/2013; 59(3). DOI: 10.1007/s10620-013-2937-x
Source: PubMed


It is well established that disparities exist for colorectal cancer (CRC) incidence rates and death. With screening, death from CRC may be considered a preventable occurrence. Endoscopy (flexible sigmoidoscopy and colonoscopy) is the only modality with therapeutic benefit of removal of pre-cancerous polyps. The Patient Protection and Affordable Care Act mandated that preventive screening services be covered, which includes endoscopy for colon cancer screening. Recent federal rules have eliminated cost sharing for polyp removal during screening colonoscopy in privately insured patients; however, this has not been mandated for Medicare patients. Understanding the current state of disparities in endoscopy use is important, as these policy changes will affect millions of patients. The purpose of this literature review was to summarize the known research on disparities in endoscopy use for colon cancer screening in the United States and highlight areas for future research.

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Available from: Andrew J. Gawron, Mar 27, 2014
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    ABSTRACT: Cellular-level studies demonstrate that the availability of the secosteroid hormone 1α,25-dihydroxyvitamin D [1,25(OH)2D] to colon cells promotes anti-carcinogenic activities. Although epidemiological data are relatively sparse, suggestive inverse trends have been reported between circulating 1,25(OH)2D concentration and colorectal neoplasia. We therefore sought to evaluate the relationship between circulating 1,25(OH)2D concentrations and odds for metachronous colorectal adenomas among 1,151 participants from a randomized trial of ursodeoxycholic acid for colorectal adenoma prevention. No relationship between 1,25(OH)2D and overall odds for metachronous lesions was observed, with ORs (95 % CIs) of 0.80 (0.60-1.07) and 0.81 (0.60-1.10) for participants in the second and third tertiles, respectively, compared with those in the lowest (p-trend = 0.17). However, a statistically significant inverse association was observed between circulating 1,25(OH)2D concentration and odds of proximal metachronous adenoma, with an OR (95 % CI) of 0.71 (0.52-0.98) for individuals in the highest tertile of 1,25(OH)2D compared with those in the lowest (p-trend = 0.04). While there was no relationship overall between 1,25(OH)2D and metachronous distal lesions, there was a significantly reduced odds for women, but not men, in the highest 1,25(OH)2D tertile compared with the lowest (OR 0.53; 95 % CI 0.27-1.03; p-trend = 0.05; p-interaction = 0.08). The observed differences in associations with proximal and distal adenomas could indicate that delivery and activity of vitamin D metabolites in different anatomic sites in the colorectum varies, particularly by gender. These results identify novel associations between 1,25(OH)2D and metachronous proximal and distal colorectal adenoma, and suggest that future studies are needed to ascertain potential mechanistic differences in 1,25(OH)2D action in the colorectum.
    Full-text · Article · Apr 2014 · Cancer Causes and Control

  • No preview · Article · Oct 2014 · Gastrointestinal Endoscopy
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    ABSTRACT: Colonoscopy in the Tilt-down Position To the Editor: Changing a patient’s body position during colonoscopy from left lateral to supine is often a helpful maneuver to advance the colonoscope (1). We have previously reported our clinical experience with placement of the patient in the Trendelenburg position as a maneuver to help negotiate a tortuous sigmoid colon (2). Steep (60o) Trendelenburg position during surgery has two reported risks: increased intraocular pressure and reduced arterial oxygen pressure (3,4). Regurgitation of gastric contents is an additional concern for the sedated colonoscopy patient especially those with a history of acid reflux. To study this technique further, three studies have attempted to address the safety and efficacy of tilting a patient downwards during colonoscopy. A pilot study of colonoscopy in the 15° Trendelenburg position throughout cecal insertion for non-obese men and women showed that there was less oxygen desaturation in Trendelenburg compared to level position (5). There was a 1-minute reduction of cecal-insertion-time in the twenty 15° Trendelenburg subjects compared to the twenty left-lateral horizontal subjects. A second study randomized 173 female subjects to left-lateral 15o tilt-down vs. left-lateral horizontal positions. It allowed enrollment of obese patients (BMI 30-34.9). All tilt-down subjects were kept in this position until the cecum was reached (6). A 10% reduction in cecal-insertion-time by use of tilt-down positioning was seen in three of five physicians (-10, -23*, -32%; * P = 0.04). When severe diverticulosis was present a trend towards reducing cecal insertion time by 1.3 minutes less in the tilt-down group was seen. Furthermore, in the left-lateral group 9% required a change to tilt-down to negotiate past a difficult sigmoid. Bradycardia occurred in none of the tilt-down subjects compared to 2 (2.3%) of left-lateral subjects. Transient oxygen desaturation occurred in 9/85 (10.6%) tilt-down and 2/88 (2.3%) left-lateral subjects (P = 0.02) and this event was associated with obesity (P = 0.02). No subject required mask-assisted ventilation or had clinical sequela including aspiration. Finally a third study included 92 non-obese women and men placed in the 15° tilt­down position during advancement through the sigmoid colon. After passage of the sigmoid the stretcher was leveled out. Application of abdominal pressure was prohibited while in this position. In these subjects there were no cardiopulmonary adverse events. A gender difference was noted for cecal-insertion-time: men (3.3 ±1.4 minutes) compared to women (4.9 ±1.8 minutes) (P <0.001) (6). From these studies and additional clinical experience, the tilt-down technique is a helpful method to assist colonoscope passage through a difficult sigmoid colon. Based on this published data, we recommend that the tilt-down position is used only during advancement through the sigmoid colon, is limited to non-obese patients, is avoided in patients with risks for regurgitation, and abdominal pressure should not be applied during this position. Leonard B. Weinstock, MD, FACG; Dayna S. Early, MD, FASGE References: 1. Rex DK. Achieving cecal intubation in the very difficult colon. Gastrointest Endosc 2008;67:938-944. 2. Weinstock LB. Body positions for colonoscopy: value of Trendelenburg. Gastrointest Endosc 2009;69:1409-10. 3. Ozcan MS, Praetel C, Bhatti MT, et al. The effect of body inclination during prone positioning on intraocular pressure in awake volunteers: a comparison of two operating tables. Anesth Analg 2004;99:1152-1158. 4. Meinninger D, Zwissler B, Byhahn C, et al. Impact of overweight and pneumoperitoneum on hemodynamics and oxygenation during prolonged laparoscopic surgery. World J Surg 2006;30:520-526. 5. Saad AM, Winn J, Chennamaneni V, et al. The value of the Trendelenburg position during routine colonoscopy: A pilot study [Abstract]. Gastroenterology 2012:A142S1:S229. 6. Weinstock LB, Early DS, Saad AM. Tilt down method for colonoscopy: novel safe and effective scope insertion technique [Abstract]. Am J Gastroenterol 2013;A1693: 108(Sl).
    No preview · Article · Oct 2014 · Gastrointestinal Endoscopy
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