Association of Race and Socioeconomic Status With Colorectal Cancer Screening, Colorectal Cancer Risk, and Mortality in Southern US Adults

Importance: Colorectal cancer (CRC) screening is rarely studied in populations who may face additional barriers to participate in cancer screening, such as African American individuals and individuals with low socioeconomic status (SES). Objective: To examine the associations of CRC screening and modalities with CRC incidence and mortality by race and SES. Design, Setting, and Participants: This cohort study used data from the Southern Community Cohort Study, which enrolled more than 85 000 participants from community health centers or stratified random sampling of the general population in 12 states in the southeastern United States. The present study included data from cohort members who were eligible for CRC screening as recommended by expert organizations based on age and family history. Participants completed questionnaires from 2002 to 2009 and were contacted again from 2008 to 2012. Linkages to state cancer registries and the National Death Index as of December 31, 2016, identified incident CRC and vital status. Data analysis was performed from January 1, 2018, to October 30, 2019. Main Outcomes and Measures: Incident CRC (n = 632) and mortality (n = 10 003). Cox proportional hazards regression models evaluated associations between screening modalities and CRC risk and mortality. Information on fecal occult blood test use was only obtained on the follow-up questionnaire. Self-identified race was measured as African American/black, white, or other, and SES was defined by household income. Results: This study included 47 596 participants (median baseline age, 54 years interquartile range, 10 years; 32 185 67. 6% African American; 28 884 60. 7% female; and 26 075 54. 8% with household income <15 000). A total of 24 432 participants (63. 9%) had never undergone CRC testing at baseline. The CRC testing assessed at baseline and follow-up interviews was associated with significant CRC risk reduction (hazard ratio HR, 0. 55; 95% CI, 0. 44-0. 70 for ever colonoscopy at baseline). Results were similar in analyses stratified by race (African American: HR, 0. 65; 95% CI, 0. 50-0. 85; white: HR, 0. 44; 95% CI, 0. 27-0. 70) and household income (<15 000: HR, 0. 63; 95% CI, 0. 46-0. 86, ≥15 000: HR, 0. 49; 95% CI, 0. 35-0. 69). Ever sigmoidoscopy at baseline was associated with CRC risk reduction (HR, 0. 66; 95% CI, 0. 51-0. 87), and undergoing fecal occult blood test in the interval between baseline and follow-up interview was associated with CRC risk reduction (HR, 0. 75; 95% CI, 0. 57-0. 98). Inverse associations were also observed between CRC mortality and receipt of colonoscopy (HR for women, 0. 39; 95% CI, 0. 21-0. 73; HR for men, 0. 69; 95% CI, 0. 40-1. 18) and sigmoidoscopy (HR for women, 0. 37; 95% CI, 0. 16-0. 85; HR for men, 0. 82; 95% CI, 0. 46-1. 47) ; however, the association did not extend to fecal occult blood test (HR for women, 1. 02; 95% CI, 0. 62-1. 70; HR for men, 1. 03; 95% CI, 0. 55-1. 93). Conclusions and Relevance: In this study, CRC test rates were low among African American individuals and those with low SES. The findings suggest that screening, particularly with colonoscopy, is significantly associated with reduced risk of CRC and mortality. The CRC disparities experienced by individuals with low SES and African American individuals may be lessened by improving access to and uptake of CRC screening.