DAY 1 - Addressing Health Disparities in Native American and Alaskan Native Populations: CRC and Liver Disease Insights and Interventions

Lukejohn Day, MD, of the University of California in San Francisco, California, described the disproportionately high rates of CRC incidence and mortality among the Native American and Alaskan Native populations in the US, with significant geographic disparities. These populations also show low and variable CRC screening rates, on average 54% compared to the low 60% range for all other racial and ethnic groups. At the same time, there is a low density of local gastroenterologists, producing deserts of GI care in the same areas with high proportions of Indigenous patients. There is also a major gap in data collection regarding CRC screening among Native American and Alaskan Native populations, with significant variation by state. Contributors to CRC screening disparities include patient-related factors, such as limited awareness and lack of education about CRC screening, native attitudes about cancer diagnosis, and mistrust of healthcare institutions. On the provider side, there is a knowledge gap within the Indian Health Service regarding when to start screening and how often. Social drivers of health also contribute to low CRC screening rates, including a high prevalence of homelessness or a lack of a permanent address, lack of smartphone access, lack of insurance, no transportation, inability to pay for tests or preps, and no time off work for healthcare. Systematic, multi-level, and combination approaches are needed that prioritize the community and patients (one-on-one or group education, partnerships with community and tribal organizations, patient reminders, culturally sensitive education); patient access (navigators, community-based FIT programs, and direct mailing of FIT); and provider delivery of care (EMR reminders, recall systems, use of advanced practice providers). As an example, the Flu-FIT Program from NCI combined CRC screening with annual flu vaccinations to increase uptake. Dr. Day noted that only 6 gastroenterologists across the entire US identify as Native American/Alaskan Native. There is a need to expand diversity among providers, as well as consider using APPs to increase access to screening.

Nicole J. Kim, MD, MPH, from the University of Washington in Seattle, Washington, described the high burden of liver disease among Native Americans and Alaskan Natives. Liver disease is the 5th and 6th highest cause of death among men and women, respectively, and is the 2nd highest in younger people, far higher than any other racial and ethnic group. Viral hepatitis B and C incidence and mortality are high in the entire population, but the landscape is changing, with increased incidence of ALD and MASLD and decrease in HCV and HBV-related liver disease. Autoimmune hepatitis incidence is also three-fold higher among Native Americans and Alaskan Natives compared to the general population. As a result, the incidence of HCC and mortality rate are double that of the general population, and mortality is expected to continue to risk disproportionately through 2040. Finally, this population receives the lowest number of liver transplants: only  1613 liver transplants have been done in American Indians/Alaskan Natives since 1988. Structural racism and discrimination, variability in healthcare access, high rates of poverty and exposure to pollution, and low insurance coverage are likely contributors to the disproportionately high rates of MASLD, cirrhosis, and HCC. Dr. Kim described the importance of partnerships to advance health equity that rely on expertise of local providers, and to stimulate research collaborations with the input of tribal councils and governing boards. The Alaska Native Tribal Health Consortium (ANTHC) is the largest and most comprehensive tribal health organization in the US, and has implemented a highly successful HBV control program involving vaccination and universal screening. They also started a prospective registry and surveillance program to monitor long-term outcomes and genotypes. The Cherokee Nation Health Services (CNHS) is the largest tribally operated healthcare system in the US, and oversees a comprehensive HCV elimination program with multimedia educational campaigns, EHR reminders, in house testing, and provider education. The Liver Cancer Disparities in AN/AI people (LICAD) group is focused on eliminating disparities in early detection of HCC, and has traveled to ANTHC and CNHS to listen, learn their current approaches, and understand the communities’ needs.

Rachel B. Issaka, MD, of the Fred Hutchinson Cancer Center in Seattle, Washington, described interventions to improve uptake of colonoscopy after an abnormal stool test among minority populations. She described an overall preference by minority patients for noninvasive and blood-based screening for CRC. However, the rate of follow-up colonoscopy after an abnormal FIT is as low as 18% in FQHCs and safety net clinics and means that CRC mortality rate remains high. The main reasons for not following up include care fragmentation, fear of the procedure and possible cancer diagnosis, and logistical barriers. Patient navigation has been associated with 13.6% increase in follow-up colonoscopy; combining navigation with mailing of FIT and monthly outreach following an abnormal result increased follow-up colonoscopy by 23%. Dr. Issaka’s institution initiated a rideshare program with Lyft Concierge to overcome transportation barriers, leveraging the existing infrastructure, payment and safety protocols, and consumer trust. A total of 256 rides were provided to people who identified transportation as the main barrier to getting a follow-up colonoscopy, with no safety issues; the average ride was $38 and 4.2 miles. Video decision aids were developed and found to decrease patient fear of prep, procedural pain, complications, and the potential for a cancer diagnosis by 18%; video education can also improve knowledge and risk calculations. Dr. Issaka noted that each intervention alone is not sufficient to reach the goal of 80% follow-up colonoscopy, and a mix of interventions at different levels are needed.

Miriam R. Perez, MS, from the University of Pittsburgh in Pennsylvania, described the results of the Alaska Fiber Intervention Research Study (FIRST), a 4-week RCT to increase dietary fiber intake in 48 Alaskan Native adults. The intervention group received a resistant starch-based diet and was found to have a more diverse microbiome compared to baseline, with a rise in butyrate and methane concentrations that aligned with increases in expression of genes encoding the relevant enzymes. The intervention group also showed a decrease in the enzyme involved in hydrogen sulfite production, which is a known CRC risk factor. Colon biopsies showed a decrease in proliferation after 4 weeks of the dietary intervention, particularly in those who had previous polyps. The results were recapitulated in a mouse model that received FMT from Alaskan Native donors. Thus, changes in diet can cause rapid and significant changes in the gut microbiome diversity and composition that favor butyrate production and minimize inflammation and proliferation.

In a panel discussion, the speakers noted that diet likely plays a role in the increased CRC risk among Native Americans and Alaskan Natives, for example, an increase in consumption of processed foods that promote inflammation. In the context of poverty and food deserts, changing diet is hard to do for these populations. 
There are some global partnerships with First Nations in Canada and the Māori people in New Zealand, but more needs to be done. The World Endoscopy Organization has a CRC Screening conference that highlights international research.
When federal funding is uncertain, healthcare systems should be encouraged to lobby state governments to support screening programs, using the business case of cost-savings of preventive medicine for the state. In lieu of state funding, the same type of business case can be made to the healthcare system.