First, the incidence of colorectal cancer has risen dramatically among adults under age 50 in the U.S. and in many countries around the world. Second, African Americans have a much greater likelihood of being diagnosed and dying from the disease at any age. Both issues are important to the public health community and efforts are ongoing to address them.
Colorectal cancer remains a major source of cancer incidence and death in the U.S. The American Cancer Society estimates that in 2020, about 147,950 people will be diagnosed with colorectal cancer and 53,200 will die from the disease, making it the fourth most prevalent form of cancer and the second leading cause of cancer mortality.
Colorectal cancer cases rise among adults younger than 50
In 2017, Dr. Rebecca Siegel and colleagues published detailed and compelling statistical data clearly bringing the issue into sharp focus, stimulating greater coverage in the media.
Analysis of trends in colorectal cancer incidence and mortality have clearly shown a decline in the general U.S. population overall during the past few decades. Unfortunately, this has not been the case for young adults.
For example, incidence has decreased by an average of 4% per year between 2007 and 2016 in those over 65 years of age, in contrast to an increase of 1.4% per year during the same period in those under 50. The observed decrease in older adults is likely due to preventive screening, which is recommended and advocated for people over 50 and has been undertaken by a larger fraction of the population.
Similarly, colorectal cancer mortality has declined by 3% per year between 2008 and 2017 in those over 65, while it has increased by 1.3% per year in those under 50.
I have met a number of young people, including several in their 20s and 30s, who had been diagnosed with colorectal cancer and were in the midst of fighting it. I have also met parents who lost young adult children to the disease, and were still trying to understand how this could have happened.
I have been struck by the intensity and complexity of emotions displayed by these people, including anger, resentment, embarrassment, hopelessness, fear and resolve. While a cancer diagnosis at any age is scary and disorienting, it extracts a particularly powerful psychological and social toll on young adults.
What is causing the increase in young adults? We do not know for certain. Several studies have indicated that the disease in young people is different with regard to the specific location of the tumor within the colon or rectum.
Also, the pathology, genetics and response to treatment differ. Lifestyle trends, such as overweight and obesity, lack of physical activity and changing diets, have been suggested to play roles. Studies have indicated that obesity is associated with increased risk of early-onset colorectal cancer in women.
While these trends may contribute, they are not fully explanatory. Physicians have told me anecdotally that many of their younger patients are thin, fit, physically active and in general good health, suggesting that something else must be going on.
What could that something else be? One intriguing possibility may lie in the billions of microbes, collectively termed the microbiota, that live on and within our bodies. Preliminary findings reported at the 2020 Gastrointestinal Symposium recently indicated that there may be differences between the microbiota within tumors from younger versus older colorectal cancer patients.
African Americans and colorectal cancer
The death of Boseman has also underscored the long-standing racial disparity for colorectal cancer. African Americans suffer from high incidences and mortalities, regardless of age. Incidence in African Americans was 18% higher than in whites during 2012-2016, while mortality was 38% higher during the same period. For reasons we do not yet know, incidence in younger African Americans has been relatively stable in contrast to that in younger whites.
Increased incidence and death from colorectal cancer in African Americans is likely a consequence of lower rates of screening, as well as environmental, socioeconomic and lifestyle factors. Reduction of the disparities may depend upon addressing these factors.
Screening can prevent colorectal cancer
Screening for colorectal cancer not only detects the disease but is also highly effective in preventing it. Screening can readily identify precancerous growths called polyps, as well as early-stage cancers. These often can be removed before they progress to life-threatening stages.
In addition, research is underway to find new methods for colorectal cancer screening based upon analysis of easily obtained body fluids such as blood and urine.
Based upon the knowledge that about 90% of colorectal cancer cases occurs in those 50 and over, the U.S. Preventive Services Task Force currently recommends that screening should begin at age 50 for those who have no predisposing symptoms. This population is experiencing the decrease in colorectal cancer incidence and death that is currently being observed overall.
But screening is not typically recommended for those under 50, and most health insurers do not pay for screening in this group.
This lack of screening, combined with a general lack of awareness about colorectal cancer and its symptoms among young people can result in late diagnoses. Later diagnoses can often result in more advanced stages of the disease, when it is harder to treat and significantly more lethal.
There is also a need to increase screening in the African American community. At present, recommendations vary. In contrast to the U.S. Preventive Services Task Force and the CDC, the U.S. Multi-Society Task Force recommends that screening in African Americans should begin at age 45 rather than 50. I hope these influential organizations will reach a consensus on this issue.
Sorting out the causes of age and race disparities in colorectal cancer incidences and mortalities, and understanding the nature of the disease more thoroughly, will take time.
As Boseman’s untimely death reminds us, colorectal cancer is a difficult and emotional disease for all people at any age. Awareness of signs and symptoms, along with engagement in screening as appropriate, will lead to the eventual eradication of the disease as a major form of cancer.
Flu season is here, and the media is filled with news about the new Covid vaccines, so this is a good time to have a sort of primer explaining the profound importance of vaccination for communities as well as individuals. [email protected], the online MSN programfrom the School of Nursing and Health Studies at Georgetown University, has kindly allowed DailyNurse to share their guide to the essentials of herd immunity and tips for addressing vaccine-hesitant patients and loved ones.
What is Herd Immunity?
Also referred to as “community immunity,” herd immunity is a public health term used to describe a case in which the potential for person-to-person spread is significantly reduced due to the broader community’s resistance against a particular pathogen.
A Glossary of Important Vaccination-Related Terms
Active immunity: Immunity as a result of the body’s antibody creation after exposure to disease-causing pathogens, either through natural infection or vaccination.
Herd immunity threshold: Also called the “critical vaccination level,” this is the approximate percentage of a population that needs to be vaccinated in order to reach herd immunity status.
Immunity: Resistance to a particular pathogen, or disease-causing bacteria, through antibodies.
Inactivated vaccine: A vaccine using a killed form of the disease-causing germ. This vaccine usually requires multiple doses over time to form immunity. Examples include the DPT and Hepatitis A vaccines and the flu shot.
Live attenuated vaccine: A vaccine using a weakened form of a germ to produce an asymptomatic infection and generate an immune response similar to a natural infection, without sickness. Examples include the MMR and chickenpox vaccines.
Natural infection: Contraction of a disease through person-to-person transmission or interaction with disease-causing bacteria.
Passive immunity: Immunity after receiving disease-fighting antibodies from an external source.
R0 (Pronounced “r-naught” or “r-zero”): The reproductive number of a disease that describes the average number of additional cases a single infected person creates.
Subunit vaccine: A vaccine using a component of the germ (such as a specific protein) to produce an immune response. This vaccine does not contain a live germ. Examples include the shingles and HPV vaccines.
Vaccine: A controlled simulation of natural infection meant to trigger antibody creation that helps fight against the disease later, without sickness.
Why is Herd Immunity So Important?
When enough community members are immune to a virus so that it inhibits spread, even those who are not vaccinated will be protected. The “herd” collectively provides insulated safety to all members, which is important for those who are too high-risk for certain vaccinations.
For these individuals, it is important that their community has built an immune response to the yellow fever so they are not at risk of infection and transmission. Individuals who are too high-risk to get a vaccination are often more likely to contract the illness and experience serious symptoms.
Some other reasons why people cannot get certain vaccinations include:
Recent blood transfusion
Underlying medical conditions like lung or heart disease
“It’s like a little nuclear circle,” she said. “So that our babies that can’t get vaccinated yet, or our pregnant mothers, or our elderly with immune systems [that] are not as robust, or people who have certain kinds of conditions that they don’t have the correct immunity, will have protection from the active pathogen that could possibly harm or kill them.”
HITs and R0s: the Science Behind Herd Immunity
In a community where no one is immune to a virus, a disease can spread rapidly and lead to an outbreak. As individuals acquire immunity, either through infection or a vaccine, the disease spreads more slowly because fewer people can pass it on.
In a community where enough members are vaccinated, the disease will stop spreading because the virus will not be able to find susceptible hosts.
The herd immunity threshold (HIT) varies depending on a variety of epidemiological factors. The primary consideration is the infectiousness of a disease. Infectiousness is measured by the Basic Reproduction Number or reproductive ratio—often referred to as R0 (“r-zero”). R0 refers to the number of cases expected to occur on average in a susceptible population as a result of infection by a single individual at the start of an epidemic before widespread immunity starts to develop. So if one person develops the infection and passes it on to two others, the R0 is 2. Herd immunity helps R0 drop below 1.
Here are some examples of R0s for a few well-known infectious diseases:
The Role Clinicians Play in Herd Immunity and Vaccination
Zschaebitz and Thompson-Brazill have years of experience in various health care settings— from travel clinics and trauma units to international research. Some of the ways that clinicians increase herd immunity and vaccination include:
participating in global research to genotype communities and help produce viable vaccines.
administering vaccines so patients can stay up-to-date on immunization schedules and travel requirements.
educating patients on the importance of vaccination and specific information related to different vaccines.
How to Talk to Patients, Family, and Friends About Vaccination
Thompson-Brazill shared her experience speaking with patients who are vaccine-hesitant and said she has learned that one of the roles clinicians play in herd immunity is educating patients about why vaccines are safe and normative for society.
Zschaebitz also shares the importance of herd immunity with patients — often through the retelling of her own experiences genotyping Maasai tribal women for an HPV vaccine.
“We were interested in preventing deaths of cervical cancer because in certain countries women just die,” she said. “Declining a vaccination is sort of a first-world problem because people in other nations would walk for miles to get what we have and what we take advantage of.”
Thompson-Brazill and Zschaebitz’s tips for speaking to vaccine-hesitant friends and family:
Tip #1: Avoid pointed questions that could make someone defensive.
Instead of: “Why wouldn’t you get the shot?” Try: “What about the shot worries you?”
Tip #2: Use storytelling as a way to share your experience.
Instead of: “I can’t believe you are not going to vaccinate your children” Try: “I chose to vaccinate my kids because…”
Tip #3: Refer people to credible, reliable sources.
Instead of: “Why would you believe that? That’s just a hoax!” Try: “The CDC has a lot of useful information about vaccines and potential risks. Have you read what they have to say?”
Tip #4: If you do not know how to respond, recommend an expert who does.
Instead of: “I can’t talk to you about this; we will never agree.” Try: “Have you shared your concerns with your clinician? They will be able to answer your questions.”
A Herd Immunity FAQ
Is it possible to achieve herd immunity without a vaccine?
No, not all diseases can be overcome with herd immunity. For example, herd immunity cannot be achieved for Clostridium tetani, the bacteria that causes tetanus. Although infection is avoidable via individual vaccination, the “herd” cannot provide protection. For example, the immunity of others will not prevent an individual from contracting tetanus after stepping on a rusty nail.
Why do I need to get vaccinated for diseases we already have herd immunity for?
Some immune responses weaken over time, which is why booster shots are so important. Additionally, vaccine refusal can lead to waning community immunity. For example, in 2019, measles outbreaks in New York and Oregon threatened the United States’ 20-year measles elimination status, according to a press release from HHS on measles outbreaks in 2019.
Is immunity from a natural infection stronger than immunity from a vaccination?
Reliable Information Sources on Vaccines and Vaccination
Both Zschaebitz and Thompson-Brazill recommend using nationally recognized, expert-led sources to learn more about vaccines, like the CDC, FDA, and NIH. Some of the additional resources available include:
CDC Immunization Schedules External link : The CDC-recommended vaccination series and timing schedule for children, adolescents, and adults.
The CDC Yellow Book External link : A set of travel health guidelines, including country-specific vaccine recommendations and requirements.
On December 14, millions watched videos of Sandra Lindsay, a New York frontline ICU nurse who lost an aunt and an uncle to Covid-19, as she became the first American healthcare provider to receive a shot after the FDA approved the Pfizer-BioNTech vaccine for use in the US. “It’s safe to take it,” Lindsay told the Washington Post,. “People have heard about the side effects — fever, arm pain — but I don’t suspect that it will be any different from the annual flu vaccine. Even if there is a little soreness, or a lot of soreness, it’s still better than the alternative.”
The few seconds it took for Dr. Michelle Chester to administer the shot marked a national milestone—a first step in the direction of herd immunity. The vaccination was also a personal milestone for the Jamaican-born Lindsay, 42, who has worked throughout the pandemic at Long Island Jewish Medical Center as an intensive care unit director in charge of five units of critical care nurses. Her brother, respiratory therapist Garfield Lindsay, said, “It’s not just managing other nurses and the stress. She has dealt with so many deaths. I reminded her how strong she is, how she prepared for this.”
After her live-streamed Covid vaccination, Lindsay became an instant social media star and was deluged with inquiries from journalists. Although the attention seemed to surprise her, she handled the questions deftly, and very much as one could expect from a long-time nurse. Was Lindsay concerned about the safety of the new vaccine? “I have no fear,” she told CNN. “I trust the science. My profession is deeply rooted in science. I trust science. What I don’t trust is getting Covid-19, because I don’t know how it will affect me and the people around me that I could potentially transfer the virus to.”
Lindsay also told CNN, “I want to be a part of the solution to put an end to this pandemic once and for all. I think also as a leader in the organization that I lead by example. I don’t ask people to do anything that I would not do myself.”
African American nurses are playing a historic role in their efforts to encourage Americans to roll up a sleeve to help end the pandemic. The example of ANA president Dr. Ernest Grant’s participation in the Pfizer-BioNTech trials depicted scientific testing in one of its most life-affirming aspects; now, Sandra Lindsay is an icon of hope in a nation longing to wake from its Covid nightmare.
People with mental illness are at greater risk for developing COVID-19 than the general population, and vice versa — meaning reverberations from the pandemic are likely to be felt long after the virus has been brought to heel.
And whether infected or not, minorities, underserved communities, and others experiencing health disparities are at double the risk of long-term mental health impacts from COVID-19.
There are “bidirectional associations” between COVID-19 infection and psychiatric disorders, explained Joshua Gordon, MD, PhD, director of the National Institute of Mental Health.
One reason that people with psychiatric disorders are more at risk for COVID-19 than others could be that they are more likely to live in congregate settings, such as prisons. Or, maybe it’s because people with serious mental illness often have other comorbidities.
Conversely, those who contract COVID-19 and do not have a psychiatric disorder have an increased risk of developing one over the next few months, Gordon said.
Roughly 6% of all patients will have “a new onset of mental illness” following a COVID diagnosis, he said.
Several surveys “of varying scientific rigor” have shown increased rates of symptoms related to mental illness in the general population, said Gordon. Symptoms not diagnoses, he stressed.
He also noted that many of these surveys used convenience samples, though the most credible of these comes from the CDC.
Despite such limitations, “every single one” has shown increases in self-reported symptoms of anxiety, depression, and “starting or increased substance abuse, ” as well as trauma, stress-related symptoms, and suicidal ideation.
About 40% of adult respondents reported challenges with “one or more” of these symptoms, which is roughly twice previous rates, Gordon said.
One potentially positive finding, while tentative, is that while suicidal ideation has increased, suicide deaths and suicide attempts haven’t yet, according to data from Greg Simon, MD, MPH, who leads the Mental Health Research Network.
The absolute number of visits for suicide attempts or self-injurious behavior appears to be “fairly steady” across 2019 and 2020 up to June, he said.
While this steady state could represent true stability in rates, it could also mean that, in the context of a lower number of overall emergency department visits, there may be more incidents but people are not seeking care.
In certain states where timely data is available, no increase in suicide deaths has occurred through the early 2020 summer, Gordon said.
As for the long-term risks of the pandemic, Gordon said most people exposed to trauma improve with time.
“A lot of people will have a lot of symptoms in the context of a disaster, but only a minority, a significant minority … will go on to have long-term or chronic experiences with mental illness as a consequence of involvement in those disasters,” Gordon said.
Those most at risk are those who have few social supports; who have a history of trauma or mental illness before the disaster; who were exposed most directly to morbidity or mortality; who had a severe acute psychiatric reaction to the disaster; or who experience ongoing stressors such as job-related or financial strains, he said.
Moreover, social inequalities and health disparities “both predict and exacerbate” the vulnerability to these long-term negative outcomes among marginalized populations.
This pandemic has had an outsized impact on minority and undeserved communities, Gordon said, which puts them “essentially doubly at risk” for long-term mental illness; not only because they are more likely to be impacted but because they are more likely to have pre-existing risk factors that raise their chances for a mental illness.
COVID and Substance Abuse
Nora Volkow, MD, director of the National Institute of Drug Abuse, said researchers have gotten creative in identifying timely data on substance use and overdoses.
Data from Millennium Health and other testing laboratories early in the pandemic showed increases of 32% in individuals testing positive for fentanyl; 20% in methamphetamine positivity; 12% in heroin positivity; and 10% in cocaine positivity.
“We don’t know what has happened in the past 6 months. But even with that restrictive data set, you can see significant increases in the positivity rate of urine that are being sent to these laboratories,” she said.
That rise in positive drug tests was found across ages and genders, Volkow said.
One program called Overdose Detection Mapping Applications, which monitors areas of high drug consumption, found significant increases in the number of fatal and nonfatal overdoses, reaching as high as 42% in May 2020 versus the same month in 2019.
Like those with serious mental illness, people with substance use disorders are also at greater risk of contracting COVID-19.
This increased risk of illness is not only due to their social circumstances and living conditions, said Volkow, but also to drugs’ physiological effects on pulmonary, cardiac, metabolic, and immune function, all of which are targeted by COVID-19 as well.
As a result, people with substance use disorders who develop COVID are much more likely to be hospitalized and to die, compared with the general population, Volkow said.
She also highlighted the significantly higher rates of deaths among African Americans than whites, likely due to their higher rates of chronic medical conditions that lead to these poor outcomes.
That further underscores the role of health disparities and the multiple factors that worsen outcomes in disadvantaged groups, Volkow said, stressing the danger of stigma, which keeps people from getting treatment, exposes them to high-risk behaviors, and leads to worse outcomes.
Volkow also warned against underestimating the “devastating” impacts of social isolation.
She cited studies showing that in “complex environments with multiple behavioral choices,” animals will not press a lever to receive drugs, whereas animals in social isolation will.
One 2018 experiment offered rats the choice between pressing a lever to get a drug and pressing a lever which enabled interaction with another rat, Volkow explained.
“When they have that choice, the animals … don’t take heroin. They choose the social interaction,” Volkow said.
When the researchers added another factor and shocked the rat for pressing the lever that offers the social reward, the rats began choosing the heroin lever instead. Volkow said the shocks’ parallel in humans represents stigma.
“If we want people to actually be able to achieve recovery, if we want to be able to prevent drug use, then we need to ensure that we are able as a society to provide social interactions that are rewarding and that are meaningful.”
By Shannon Firth, Health Policy and Washington Correspondent, MedPage Today
The Texas Nurses Association (TNA) has a rich history of accomplishments and has played a key role in setting educational and workplace standards for nurses in the state. Today, the TNA is still tirelessly advocating for nurses and patients in Texas. As the state struggles with a frightening surge of Covid-19 cases, DailyNurse asked Cindy Zolnierek, PhD, RN, CAE, CEO of the TNA, about the most pressing healthcare issues in America’s second largest state. In Part One of this two-part interview, Zolniek spoke about the challenges of fighting Covid-19 in Texas. (Part Two will publish tomorrow.)
DailyNurse: Some aspects of Texas geography must present serious healthcare challenges even in the absence of a major public health crisis.
Cindy Zolnierek: “We do have these great expanses, and they tend to rely on critical access hospitals. [Critical access] hospitals take care of basic emergencies, but they’re very used to shifting patients off to larger facilities and other communities. This has long been standard practice in the areas of the state that have those largest expanses like West Texas. After you leave that El Paso, you go a long ways before you hit another decent sized city. [It’s] the same with Amarillo and Lubbock, Laredo, and the Midland Odessa area, which are some of the hardest hit areas [by Covid-19] in Texas. And now, with those hospitals being full, overflowing with patients to critical access, hospitals are left with no place to send their patients to. So it’s not just the communities themselves that are impacted—it’s the whole system, the whole infrastructure for providing health care, and care for cases like strokes and heart attacks and highway accidents is being impacted significantly.”
DN: So the whole healthcare system is being placed under severe strain during the pandemic?
Zolnierek: “Well, [normally] patients go to the nearest facility, like a critical access hospital, which patches them up, does the assessment and anything you need to do for life-saving. They then send the patient to a trauma facility. [During the pandemic] the problem has been. . . Click here to read the rest of this article.
As hospitalizations and deaths mount, nurses are losing patience with COVID-19 conspiracy theories and distorted libertarian mores that depict masking mandates as an infringement of personal liberty.
For frontline nurses tending to Covid patients who shunned masks or insisted on attending crowded gatherings, the situation is fraught with tragedy. South Dakota ED nurse Jodi Doering recently told CNN, “I think the hardest thing to watch is that people are still looking for something else and a magic answer and they do not want to believe Covid is real. Their last dying words are, ‘This can’t be happening. It’s not real.’” In North Dakota, Governor Doug Burgum pleaded, “You don’t have to believe in Covid, you don’t have to believe in a certain political party or not, you don’t have to believe whether masks work or not. You can just do it because you know that one thing is very real. And that’s that 100 percent of our capacity is now being used.”
Nebraska ICU nurse Laci Gooch spoke out in a Twitter video: “We’re tired. We’re understaffed. We’re taking care of very, very sick patients and our patient load just keeps going up. We’re exhausted and frustrated that people aren’t listening to us.” Driving home after one night shift, Gooch passed a car festival packed with attendees blithely ignoring masking and social distancing, and “I was just shocked and it was infuriating. It just kind of feels like a slap in the face to all the hard work that we’re doing.”
Kentucky nurses, too, are “tired and frustrated” by the neglect of social distancing rules. Delanor Manson, of the Kentucky Nurses Association, told WLKY, “Some of the things that make it especially hard for [frontline nurses] is that they can’t get the vision of people dying out of their heads when they’re sleeping at night and when they’re at home with their families.”
There is irony as well. Despite being acclaimed as “healthcare heroes” around the globe, nurses feel doubly vulnerable when they go home to communities that frown on masking. “Wearing a mask won’t hurt you, but there’s the potential if you don’t wear a mask you may hurt someone else,” said Dr. Ruth Carrico, an infectious disease nurse and researcher with University of Louisville Health in Kentucky. In Pennsylvania, Tiffany M. Montgomery, a Drexel University postdoctoral research fellow who also works as a labor and delivery nurse, told the Morning Call, “I had no idea we would be doing it for this long and I’m just tired. I don’t want to be your superhero. I want to be safe. I don’t want to have to deal with this anymore. I want you to listen to health care providers and [what] your officials are telling you. I don’t want praise and I certainly don’t want to be your martyr.”