Who isn't receiving colorectal cancer screening?

- Jennifer Middleton, MD, MPH

The U.S. Preventive Services Task Force recently updated its colorectal cancer screening recommendations, affirming its prior “A” grade for adults aged 50 to 75. While screening rates in the U.S. have increased over the past decade, there is still room for improvement, especially among uninsured individuals, some minority populations, and immigrants. A 2010 systematic review found lower rates of colorectal cancer screening among Hispanic and Asian Americans, along with anyone born outside of the United States. A more recent study found even lower rates among Spanish-speaking Hispanics compared to English-speaking Hispanics. Differences in access to care only accounted for some of these disparities.

Successful strategies that increase screening rates include providing fecal occult blood tests in a manner that addresses language barriers, and providing culturally appropriate patient education materials and/or 1-on-1 contact with a nurse or health educator. Additionally, the state of Michigan partnered with a large health insurer to mail reminder cards about colorectal cancer screening, which increased uptake by 16%; in Wisconsin, providing grants for screening events in underserved communities also increased screening rates. Adding a telephone call to a reminder letter increased screening rates in New York, but telephone calls by themselves did not. Ensuring adequate physician access for minority and underserved populations also increases screening; one study found that the distribution and supply of family physicians and gastroenterologists correlates with better screening rates.

Although many practices track their overall colorectal cancer screening rates, this figure may mask variations by race, ethnicity, or foreign-born status. Recognizing screening disparities is an important first step. Trying one or more of the above interventions to improve screening rates in underserved populations with a Plan, Do, Study, Act (PDSA) cycle might then be a reasonable next course of action. There’s a recent AFP article on Colorectal Cancer Screening and Surveillance if you’d like a refresher on recommended screening methods.

Overcoming obstacles to HPV vaccination

- Kenny Lin, MD, MPH

Human papillomavirus (HPV) vaccines, which prevent infection with HPV genotypes that cause cervical, anal, vaginal, and penile cancers, are hardly new. The quadrivalent and bivalent HPV vaccines were reviewed in AFP in 2007 and 2010, respectively, and a 9-valent vaccine was approved by the U.S. Food and Drug Administration in 2014. Although long-term studies have yet to demonstrate that HPV vaccines reduce cancer rates, a recent systematic review found that introduction of the quadrivalent vaccine in 9 countries (including the U.S.) was associated with a 90% reduction in infections from the targeted genotypes and similar reductions in genital warts and high-grade cervical abnormalities. Women who receive HPV vaccine are at considerably lower risk for undergoing colposcopy and associated invasive diagnostic or therapeutic procedures.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends that all boys and girls receive the 3-dose HPV vaccine series at age 11 to 12. However, CDC data from 2014 show that only 40% of girls and 21% of boys had completed the series by age 17. In contrast, 80% of 13 to 17 year-olds had received meningococcal vaccine, and 88% had received TdaP (tetanus, diphtheria, and acellular pertussis) vaccine, which provide protection against serious, but comparably rare, infections. Earlier this year, all 69 National Cancer Institute-designated Cancer Centers released a consensus statement expressing concern about persistently low HPV vaccination rates in the U.S. compared to other countries, which they labeled a "serious public health threat."

A 2015 AFP editorial by Drs. Herbert Muncie, Jr. and Alan Lebato examined parental and physician impediments to HPV vaccination. Parents often express concerns about vaccine safety and worry that their children may be more likely to start having sex after receiving the vaccine. Family physicians can reassure parents on both of these questions:

Parental safety concerns about the HPV vaccine increased from 4.5% in 2008 to 16% in 2010, although the reported adverse effects have been minor (e.g., injection site reactions, syncope, dizziness, nausea, headache). Studies have shown that adolescents who receive the HPV vaccine do not initiate sexual activity earlier, nor is their risk of acquiring an STI increased.

In other cases, physicians have been the primary obstacles to vaccination: they are sometimes reluctant to bring up the topic of sex, they believe the vaccine is unnecessary because Pap smears will detect early cervical cancer, or they present the vaccine as "optional" or don't offer it at all. Drs. Muncie and Lebato suggested several effective strategies for improving HPV vaccination rates:

Instead of discussing the vaccine as a means of STI prevention, physicians can present it as a way to prevent cervical cancer in women and oropharyngeal cancer in men. They can mention that immunologic response is greater in younger adolescents, so earlier immunization is prudent. Physicians should encourage HPV vaccine administration at the same time that other adolescent vaccines are given. They should review immunization status at every visit, and administer the HPV vaccine at any time—including during sick visits.

An editorial in AFP's July 15th issue by Drs. Jamie Loehr and Margot Savoy provided additional tips for physicians on addressing and overcoming vaccine hesitancy in general. More immunization resources, including the latest childhood and adult immunization schedules from the ACIP, are available in AFP's Immunizations Topic Collection.

Relieving chronic work-related pain and job insecurity

- Marselle Bredemeyer

A Curbside Consultation article in AFP’s July 15th issue highlights the difficulties that immigrants working in low-wage jobs experience when it comes to addressing workplace hazards without the support of advocates and health care professionals. This challenge is not unique to immigrants, although they are disproportionally affected; underreporting of workplace injuries is a widespread problem. The Occupational Safety and Health Act, which was passed in 1970, covers persons working in nearly all sectors and protects all employees regardless of immigration status.

The Occupational Safety and Health Administration (OSHA), formed to enforce elements of the labor act, has its weak points, however. In a response to recent requests that sought reduced production line speeds at poultry plants, an OSHA representative cited “limited resources” as one factor precluding the implementation of definitive rules from being considered. The expectation for employers is broad, in any sense—they have a “general duty” to ensure a safe workplace.

Where does this leave patients like the one in the Curbside Consultation article? Although workers can’t anticipate that there are explicit regulations applying to individual aspects of their job, such as the amount of weight they are permitted to lift, there are actions that can be taken—like those described in the article commentary—to prevent long-term injury from repetitive motion.

Unlike the legal right to work in a safe environment, immigration status has a huge bearing on a person’s access to health care. In the case scenario described in the journal feature, the patient’s Cuban origin ensured her Medicaid eligibility for a temporary time. Many immigrants who are legally present are ineligible for Medicaid for five years after arrival, however, and those who are undocumented cannot shop for private coverage on the Patient Protection and Affordable Care Act’s (ACA) exchanges. Refugees and asylees, along with other select groups, whether from Cuba or dozens of other countries, have immediate access to health care assistance for at least eight months.

There are still a number of questions that researchers need to tackle regarding occupational health among immigrants. How can employers reduce the undue risk of harm migrants face in the workplace? Why does this disparity exist? Fear of job loss is, unfortunately, all too often well founded. Family physicians who are aware of existing labor protections and legal and community resources can not only guide the treatment of occupational disorders, but also empower patients who choose to take steps to improve workplace safety. Without a physician to take a directed history in the first place, connections between acute and chronic illnesses and workplace conditions will remain in the dark.

Virtuous cycling: lower diabetes risk, but wear a helmet

- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH

I (Jennifer) live in a community with a wonderful bicycle path system, and around this time of year it gets a lot of use. In a 2011 Letter to the Editor titled "The Virtuous Cycle," AFP Deputy Editor Mark Ebell, MD, MS encouraged readers to advocate in their communities for "safe, convenient, and enjoyable places to walk, run, and bike" rather than continuing to "harangue our patients about exercise and be frustrated when they do not listen to us."

Sensible advice, but do recreational and commuter cyclists have better health outcomes than non-cyclists, is it enough to cycle during only part of the year, and is it ever too late to get on the bike? A prospective cohort study of more than 50,000 Danish men and women recruited between the ages of 50 and 65 and followed for an average of 14 years recently provided answers to these questions. In a multivariable analysis, both seasonal and year-round cyclists had up to a 20 percent reduced relative risk for developing type 2 diabetes, even if they started cycling late in life.

The health benefits of cycling can be easily negated, though, by the risks of not wearing a helmet. Even though helmet-wearing cyclists are more likely to survive trauma than those not wearing helmets, and despite laws mandating helmets across the country, many bicycle riders continue to go bareheaded. A 1999 survey found the most common reasons for not wearing a helmet included "uncomfortable," "annoying," "it's hot," "don't need it," and "don't own one." This survey also found that peer and/or parent wearing of helmets increased the likelihood that children wore them too.

A review of children's cycling accidents from the National Trauma Data Bank found that white children and/or children with private insurance were much more likely to wear a helmet than African-American children and/or children with Medicaid. Another study in Los Angeles County found lower helmet use among older children, non-white children, and children from a low socioeconomic status. Programs that give away free helmets to children either in schools or in physicians’ offices increase helmet use and may reduce health disparities. Although physician counseling also increases helmet wear in patients under age 18, in one survey less than half of physicians providing care to this age group provided it. Unfortunately, there haven't been any studies of interventions to increase helmet wearing in adults.

The bottom line is that encouraging patients to start cycling for long-lasting health benefits should be accompanied by counseling on the importance of wearing helmets.

Guest Post: preventing sexual assualt

- Yalda Jabbarpour, MD

“You don’t know me, but you’ve been inside me, and that’s why we’re here today.” So began the statement of Brock Turner’s victim at his sentencing this spring. Turner, a former Stanford University student, was found guilty of three counts of sexual assault, but his 6 month sentence sparked outrage. Although this case brought renewed interest to the problem of sexual assault, the sad truth is that it is not unique. A recent poll conducted by the Washington Post and Kaiser Family Foundation found that 20 percent of young women reported being sexually assaulted on their college campuses in the past four years. 1 in 5 women. As a mother and family physician who cares for adolescents, these statistics are frightening, especially considering the life-long physical and psychological consequences for the victims.

According to a 2010 article in AFP, sexual assault is associated with sexually transmitted infections (STIs), posttraumatic stress disorder, anxiety, depression, chronic pain syndromes, drug and alcohol abuse, irritable bowel syndrome, headaches, fibromyalgia and sexual dysfunction. Sexual assault is a true public health crisis. What can family physicians do to curb this epidemic?

Much of the literature on the physician’s role in sexual assaults deals with the aftermath: collection of the rape kit, post-exposure STI prophylaxis, identifying and treating long term physical and psychological sequelae. But I would argue that, as is the case in much of what we do, prevention is the key. I propose we start by defining the problem for our patients. In the Post/Kaiser poll, 46 percent of college-aged respondents said it’s unclear whether sexual activity that occurs when both people have not given clear agreement constitutes sexual assault. This means that we need to have open and honest conversations with adolescents and young adults about the need for both parties to give consent before having sex. Establishing rapport is key to broaching sensitive topics with adolescents, and to do this, it is important to ask adolescents specific questions about their practices rather than stating general facts.

Once we have defined the problem, we need to counsel patients on the risk factors associated with it and how to mitigate those. Race, ethnicity, social class, study habits or religious practices were not related to sexual assault in the Kaiser poll. However, women who said they sometimes or often drink more than they should are twice as likely to be victims of completed, attempted or suspected sexual assault compared with those who rarely or never do. Therefore, counseling men and women on responsible drinking strategies—such as using a buddy system, pouring their own drinks, and knowing their limits—is key.

Certainly, physicians alone cannot solve the issue of sexual assault, but we should consider addressing it in every preventive health discussion we have with college-aged students. When sharing her solidarity with other victims of sexual assault, the Stanford victim appropriately quoted Anne Lamott: “Lighthouses don’t go running all over an island looking for boats to save; they just stand there shining.” It may not be within our power, or our job description, to stamp out sexual assault, but physicians can serve as lighthouses, helping to illuminate for our patients a safe path through their college careers.

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Dr. Jabbarpour is the Robert L. Phillips, Jr. Health Policy Fellow at Georgetown University School of Medicine.