Traditionalism and Colorectal Cancer Screening among Reservation American Indians

1. Traditionalism and Colorectal Cancer Screening among Reservation American Indians David G. Perdue MD MSPH University of Minnesota Division of Gastroenterology

3. Background: Colorectal Cancer In Indian Communities

4. Colorectal Cancer Normal Colon Polyp ColonCancer Colon Cancer Prevented! Polypectomy

5. Current Screening Options Colonoscopy every 10 years OR FOBT (on 3 consecutive stools) Yearly AND Flexible Sigmoidoscopy Every 5 Years OR Barium Enema Every 5 Years

6. Invasive colorectal cancer incidence by region, 1999-2002 AI/AN in CHSDA counties and All Races Combined in RegionAge 50 and Over 32% Higher Incidence in Northern Plains American Indians AK/SW 6 fold Difference AI/AN Cases 211 272 435 65 278 176 AI/All Races RR 1.75 1.32 1.24 0.78 0.88 0.39 Source: Prelim_NPCR_SEER_AgeGroups_08_17_06.doc.Note: All races combined not limited to CHSDA

7. Barriers Can Lead to Cancer • Individual and Community Barriers • -Unaware of Risk or Denial • -Fear of Pain or Embarrassment • -Cultural Beliefs • Financial Barriers • -No insurance • -Fear of liability • -Need to miss work • -Need for a ride No Screening No Preventative Polypectomy Later Stage Diagnoses?? • Institutional Barriers • -Discomfort with medical system • -Physician not recommending • -Unclear of risk • -Competing priorities • -Time constraints • -Endoscopic capacity • -Distance to services

8. Traditionalism and Colorectal Cancer Screening among American Indians • University of Minnesota • David G. Perdue, MD, MSPH • Black Hills Center for American Indian Health • Jeffrey A. Henderson, MD, MPH • University of Washington • Andrew Bogart, MS • Yang Wen, MS • Jack Goldberg, PhD • Dedra Buchwald, MD

9. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Education and Research Towards Health (EARTH) • 5 yr multi-center prospective cohort • Determine how diet, physical activity, and other lifestyle and cultural factors relate to the development and progression of chronic diseases, including cancer • PIs: • Black Hills Center for American Indian Health: • Jeff Henderson MD MPH • Alaska Native Tribal Health Consortium: • Anne Lanier MD MPH • University of Utah • Marty Slattery PhD MPH

10. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • AIMs • Describe the self-reported CRC screening test utilization among AIs > 51 years of age • Test hypothesis that AIs who maintain their traditional culture are less likely to have had CRC screening

11. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Subjects • BHCAIH Cohort: n= 5,212 • Age 51 or over: n= 867 • Complete data, no history CRC FOBT: n= 717 Endoscopy: n= 751

12. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • CRC Screening Questions: • Based on BRFSS • “Did you ever have a test to see if there is blood in your bowel movement also called a fecal occult blood test or FOBT?” • “Did you ever have a colonoscopy or sigmoidoscopy? These are tests in which a tube is inserted in the rectum to view the bowel.”

13. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Traditionalism Constructs: • Traditional Healing Practices • Cultural Identity

14. Traditionalism & Colorectal Cancer Screening among Reservation American Indians Traditional healing practices questions • “Have you ever been treated by a traditional Native healer” • “Do you use traditional Native remedies and or practices to remain healthy (prevent illness)?” • “Do you use traditional Native remedies and or practices when you are sick or ill?”

15. Traditionalism & Colorectal Cancer Screening among Reservation American Indians Cultural Identity Questions: • “What language do you usually speak at home, your own American Indian language, English, or both?” • “How much do you identify with your own tribal tradition?” • “Do you ever participate in Native dances, powwows, potlatches, chicken scratch dances, sweats, or other such traditional events as a dancer, drum member, organizer, or other active participant?”

16. Traditionalism & Colorectal Cancer Screening among Reservation American Indians Adjustment covariates: • Age • Education • Employment, • Single caregiver • Marital status • Smoking history • Reservation of residence • Status as a current driver

17. Traditionalism & Colorectal Cancer Screening among Reservation American Indians Statistical Analysis • Frequencies and proportions • Sociodemographic: age, income, dependents, education, employment and marital status. • Ecological: reservation, driving status, single care giver • Traditional healing practices • Cultural identity • Association between traditional healing practices and cultural identity with the receipt of CRC screening • logistic regression analysis. • Adjusted odds ratios and 95% confidence intervals • Association of our summary (ordinal) measures of traditional healing and cultural identify with CRC screening • test for trend from logistic regression.

18. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Results • Any CRC screening: 35% • FOBT • Arizona: 23% (versus state BRFSS 31%) • South Dakota: 20% (versus state BRFSS 27%) • Endoscopic • Arizona: 22% (versus state BRFSS 52%) • South Dakota: 21% (versus state BRFSS 50%)

19. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Factors Associated with Screening • Associated with FOBT • Education Level (p =0.02) • Former or non-smoker (p <0.01) • Associated with Endoscopy • Income (p < 0.01) • Education Level (p < 0.01) • Married (p < 0.01) • Former or non-smoker (p < 0.01) • Current Driver (p = 0.02)

20. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Unadjusted Summary Comparisons • Traditional Healing Use Questions • FOBT: None significant • Endoscopy None Significant • Cultural Identity Questions • FOBT None Significant • Endoscopy Native Language at home p<0.01

21. Traditionalism & Colorectal Cancer Screening among Reservation American Indians None meet significance

22. Traditionalism & Colorectal Cancer Screening among Reservation American Indians

23. Traditionalism & Colorectal Cancer Screening among Reservation American Indians

24. Traditionalism & Colorectal Cancer Screening among Reservation American Indians

25. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Summary Results: • FOBT and endoscopic screening are lower in AI than non-AIs living in the same state • Those with higher education attainment and former smokers had the highest likelihood of reporting FOBT and endoscopy • Higher incomes, married, and current drivers where more likely to have had endoscopy

26. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Summary Results • Those who spoke their Native language at home where less likely to have had endoscopy • None of the other traditionalism questions met statistical significance • However, the direction of association all questions was away from screening

27. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Trend Analysis • A significant trend away from FOBT was seen with increasing positive responses to the traditional medicine use questions • A significant trend awayfrom endoscopic screening was seen with increasing positive responses to the cultural identity questions

28. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Limitations • Traditionalism is a complex metric that varies by tribe and geography • CRC screening was self-reported • Probable many tests were for symptoms, not screening • Lack of data on factors known to alter odds of screening • Having a primary physician who recommends screening • Insurance status

29. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Conclusions • American Indians experience disparities in CRC burden • Screening disparities likely play an important role • Constructs of traditionalism affect CRC screening participation in complex ways • More work is needed to understand the individual, community, and institutional barriers to and determinants of CRC screening participation so durable, culturally-specific CRC screening programs can be developed

30. Questions?