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Dr. Chyke Doubeni believes he has answers to closing the colon cancer mortality gap between Black communities and white populations.
“They’re actually surprisingly simple,” said Doubeni, an epidemiologist and health services researcher who heads the Mayo Clinic’s Center for Health Equity and Community Engagement Research, which works out of Rochester and other Mayo facilities.
In fact, one health clinic in south Minneapolis already has assembled a successful track record of closing those gaps with culturally responsive care.
But first, the disparities. According to Doubeni’s research, across the United States, the colon cancer mortality rate for Black men stands at 21.3 deaths per 100,000 people, compared to a death rate of 15.5 per 100,000 white men. Doubeni did not measure the mortality rate statistics for Minnesota, but says with confidence that “the gap exists in every state.”
One disparity in Minnesota is clear: People of color get screened for colon cancer much less often than the state’s white population. A report released in May 2021 from the nonprofit health-care research group MN Community Measurement found 75 percent of white adults between the ages of 50 and 75 were up to date on colon cancer screening, compared to 59 percent of Black adults in that age group.
One of the report’s findings suggests an even bigger disparity in East African communities: Just 34 percent of adults who prefer to speak Somali as a primary language were up to date on their colon cancer screening. (Similarly, 35 percent of adults in the same age group who listed Somalia as their country of origin were up to date on screening.)
Doubeni cites “the social determinants of health” as the main reason for these disparities. He lists a few examples to make his point: lack of access to cancer screening, lack of access to early cancer diagnosis, lack of access to treatment, lack of transportation to get to the treatment.
Being overweight, obese, or eating a poor diet can increase the risk of colon cancer, Doubeni added, and all of these conditions are “strongly correlated with socioeconomic status.”
So what, then, are those “surprisingly simple” answers to closing disparities that Doubeni mentioned? For starters, he says, everyone needs to have easy access to cheap colon cancer screening.
“How do you do that?” Doubeni asked. “Engage with the community to understand what the barriers are.”
One of the biggest barriers to colon cancer screening and treatment is a lack of health insurance and underinsurance, he said. Public insurance programs like Medicaid and Medicare don’t always reimburse for cancer treatment as well as private insurance does, he added.
“What the insurance company pays is sometimes the determinant of whether or not you’re going to die,” Doubeni said. “Why should that be, in this country?”
Introducing the concept of preventative care
In 2018, a team of medical professionals put similar recommendations to work. The effort to increase screening rates came from a partnership between the Minnesota Department of Health and Axis Medical Center, a federally qualified health care center in Minneapolis that serves a large East African patient population.
The Health Department’s Sage Screening Program provides free cancer screening for low-income patients. Sage paid for a patient navigator, who acts as a bridge between patients and their healthcare providers, to bring up the clinic’s abysmally low colon cancer screening rates. At the time, less than 1 percent of the clinic’s eligible patients were getting screened, said Jonathan James, the clinic’s epidemiologist.
“Colon cancer is something that, if detected early, is widely survivable,” James said. “So we recruited a person to specifically work on colorectal screening.”
Bashir Moallin filled that role. Bashir grew up in Somalia and studied medicine in Jordan. Shortly after receiving his medical degree, he traveled to Minnesota. At the time, he was trying to get into a residency program to complete his medical training. The Sage program was hiring international medical graduates like him.
Bashir already knew some of the major reasons for why these health disparities existed. As a boy growing up in Somalia, his family would go to a hospital or health clinic only if someone was really sick, he recalled. Health visits were expensive, and patients like his family had to pay out of pocket.
“There is no concept of preventative care in our background,” he said.
Many in the community are also unfamiliar with screening procedures like sending a sample of your own stool to a lab for testing. That’s even more true for colonoscopies, which involve anesthetizing a patient and inserting a colonoscope—a camera connected to a thin tube—in the rectum. A doctor guides this device through the colon to look for polyps: abnormal bumps that can grow in the colon and turn into cancer.
Blood in stool can be a sign of existing polyps. If polyps are found during the colonoscopy, the doctor uses a small blade in the colonoscope to remove them.
Preparing for a colonoscopy can be quite unpleasant. During the days leading up to the procedure, patients must eat low fiber foods and then no solid foods the day before. They must also drink large volumes of laxatives and, for their own good, remain very close to a toilet. Ultimately, the test can demand multiple days off from work.
Another obstacle? Cancer screening is usually just one of many different topics a doctor will bring up with a patient during a visit.
“It’s very tough for providers to have enough time to educate patients,” Bashir said. “Some clinic visits are only 20 minutes, and the patients can have multiple complaints.”
Finding the right words in Somali to describe a polyp
Mike Flicker, who at the time served as the clinical services director for the Sage program, cited many reasons for the discrepancies.
“It’s a bias against an invasive procedure like a colonoscopy, which I get,” Flicker said. “And handling poop, who wants to do that?”
Another obstacle is the language barrier. “How do you describe polyps and how do you describe these procedures, which use words that are often only in English?” Flicker said.
To break the stigma and make the topic accessible, Bashir would first educate patients about the risks and dangers of colon cancer. This would usually happen in the clinic after a regular patient checkup. Bashir also knew which patients to target: Axis kept a list of all eligible patients who weren’t up to date on their colon screenings.
Bashir’s fluency in the Somali language was essential. So was his patience.
“We tried to explain these things as easily as possible,” he said. “People would listen. They might not want to get screened still, but they would listen.”
It also took persistence. Sometimes that meant gently nudging a patient through multiple conversations during visits to the clinic, over a period of months. One thing that helped out immensely is offering less invasive, less costly alternatives to colonoscopies, like sending a stool sample to the lab.
“With Somali patients, they always avoid the colonoscopy,” Bashir said. “But people were accepting of the stool test. When we started offering it, the screening went up.”
Other gestures helped. Bashir often personally picked up stool samples from patients’ homes, even during his off hours, to make sure they made it to the lab.
Stool samples involve sending a sample to test for the presence of blood. The tests are cheap—roughly $50 compared to upwards of $3,000 for a colonoscopy. And they don’t involve the uncomfortable preparation that comes with the procedure. If blood is found in the sample, doctors recommend a colonoscopy as a followup.
A reluctant patient becomes a family health advocate
All of the patients who submitted a stool sample that revealed blood went forward with colonoscopies, Bashir said. For patients who got to this point, the fear of not getting treated outweighed their fear of going through the procedure.
Bashir recalls one patient in particular who took four conversations over several months before finally agreeing to a stool sample. The patient had a family history of colon cancer, and his stool sample contained blood. During the colonoscopy, the doctor found and removed multiple polyps on the patient.
Later, this same patient convinced many of his family members, who were neglecting screening, to get tested.
It’s persistence like this that can ultimately save lives, Bashir said.
The effort between Sage and Axis led to success as well. Axis’s colon cancer screening rate went from less than 1 percent to more than 20 percent between 2017 and 2018. The increase was so dramatic that it caught the attention of the Centers for Disease Control and Prevention.
PQ: The Axis clinic’s colon cancer screening rate went from less than 1 percent to more than 20 percent between 2017 and 2018. The increase was so dramatic that it caught the attention of the Centers for Disease Control and Prevention.
Three representatives from the CDC flew from Atlanta to the Twin Cities and visited Axis to learn how the program worked.
“If you have someone like us, with the language background and the culture background to just do the job of screening, you have a lot of time to address the issue,” Bashir said.
The start of the COVID-19 pandemic halted the momentum to screen for colon cancer at Axis and elsewhere. As clinics limited care and encouraged people to stay home and mitigate the spread of the virus, screening rates went down, James said.
But the clinic is working on ways to get cancer screening on patients’ minds again.
“Yes, COVID is emergent and we need to focus on vaccines, but that can’t mean we ignore something as primary as cancer screening,”James said.
Bashir, however, may not be part of that Axis effort. In 2020, Bashir started medical residency in family medicine at the University of Minnesota. Now in his second year of residency, Bashir works in St. Cloud at CentraCare Family Health Clinic.