In Search of a Perfect Solution to Ensure that “No Colon Is Left Behind”

It is well known that blacks suffer a disproportionately higher burden from colorectal cancer (CRC) [1, 2]. However, the root cause of the problem and hence, the perfect solution to eliminate this major public health problem is unclear. Several possible causes have been identified as contributory to this problem but can be broadly classified into three domains: healthcare access, healthcare utilization and biological differences. Healthcare access differences: CRC screening is an elective medical care. Therefore, having healthcare insurance is sine qua non for getting optimal medical care including CRC screening. In the United States, blacks tend to have lower socioeconomic status and lack health insurance coverage. This has been associated with lower CRC screening rates [3]. Healthcare utilization differences: Research has shown that blacks tend to underutilize healthcare resources when compared with whites even within the same healthcare system [4, 5]. Some of the reasons underlying this difference may be care provider factors such as lack of CRC screening recommendations [6] or patient factors due to mistrust of the medical system and poorer healthcare education [7]. Adoptions of medical advances also lag behind among blacks [8]. Biological differences: Studies have suggested that CRC burden differences may be due to differences in tumor biology by race. The prevalence of CRC risk factors including economic factors is fairly comparable between Hispanics and blacks, yet Hispanic Americans consistently have lower CRC incidence and mortality when compared to non-Hispanic whites and blacks [1, 2]. Earlier age of CRC diagnosis, late stage presentation and proximal location of CRC have been reported among blacks as compared to whites [9, 10]. However, most studies that have investigated CRC disparity by race have been limited by non-screening populations, small sample sizes, single institution experience, retrospective designs, and lack of histopathologic diagnosis [2–11]. The critical challenge is to understand the differential contributions of these three domains to CRC disparity by race such that interventions can be prioritized accordingly. Unfortunately, no study has evaluated this. The ongoing Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) provided an opportunity to evaluate two of these three domains within the same cohort of participants who underwent trial sponsored flexible sigmoidoscopy and suggested that healthcare utilization differences may be playing more of a role than biology [12]. At the present time, stakeholders have adopted different strategies to address this public health problem. The Center for Disease Control established the Colorectal Cancer Control Program (http://www.cdc.gov/cancer/crccp/about. htm) which will provide funding to 25 states and four tribes across the United States in order to increase CRC screening rates to 80% in the funded states by 2014. The District of Columbia Cancer Consortium also instituted an ongoing 1 year DC Screen for Life program to educate 1,000 DC residents and provided funds to screen 600 uninsured and underinsured 50–64-year-old DC residents with colonoscopy and fecal immunochemical tests (DC Screen for Life: http://cancer.howard.edu/patients/screening.htm; http://www.cdc. gov/cancer/npcr/success/south/dc/dc1.htm). In New York, a 20% improvement in colonoscopy screening in New York City A. O. Laiyemo (&) Division of Gastroenterology, Department of Medicine, Howard University College of Medicine, 2041 Georgia Avenue, NW, Washington, DC 20060, USA e-mail: adeyinka.laiyemo@Howard.edu