As the country celebrates the cultural diversity of Asian Americans, Native Hawaiians, and Pacific Islanders in May for Asian/Pacific American Heritage Month, it is time for a reminder for members of those communities to keep up with their cancer screenings. Specifically, experts at the Mount Sinai Health System are calling on Asian American and Pacific Islander (AAPI) people to be vigilant about breast and colorectal cancer screenings.
“Breast cancer is the leading cause of cancer death for women worldwide, and the second leading cause of cancer deaths for women in the United States,” says Desiree Chow, MD, Assistant Professor of Medicine (General Internal Medicine) at the Icahn School of Medicine at Mount Sinai. “However, for Asian Americans and Pacific Islanders, these groups have been found to consistently score lower than their non-Hispanic white counterparts for breast cancer screening.”
A similar theme echoes in colorectal cancer, notes Sanghyun (Alex) Kim, MD, Chief of Colon and Rectal Surgery at Mount Sinai Beth Israel, Mount Sinai-Union Square, and Mount Sinai Morningside. “Not only are we seeing lower screen rates for AAPI communities in colon cancer, but over the last 20 years, we’ve seen a twelvefold increase in colon cancer rates in these populations,” says Dr. Kim. “This is why it’s very important for physicians who see AAPI patients to be proactive in reminding them to be screened regularly.”
Left: Desiree Chow, MD. Right: Sanghyun (Alex) Kim, MD.
What are the disparities in cancer screening rates among different races/ethnicities?
While breast and colorectal cancer screening rates have steadily grown over the years, Asian American and Pacific Islander (AAPI) populations screen at a lower rate than the non-Hispanic white population. Here’s a snapshot of how each group screens for those cancers from 2008 to 2018, according to a report from the Centers for Disease Control and Prevention (CDC).
Source: Health, 2019, National Center for Health Statistics, CDC
As the COVID-19 pandemic hit, screening rates declined in 2020—by as much as 97 percent for breast cancer for AAPI communities compared with the previous five-year average, according to an April 2023 memo from the CDC. To address the decline in screening among certain populations, the agency is partnering with health care providers to resume timely use of preventive tests for early detection of breast, cervical, colorectal, and lung cancers.
Drs. Chow and Kim share their thoughts on the importance of being up to date with breast and colorectal cancer screenings, respectively.
Why are we calling for our AAPI communities to be vigilant about breast and colorectal cancer screening?
Dr. Chow: In general, Asian American women tend to have dense breasts, which is an independent risk factor for breast cancer and it decreases the ability for mammograms to detect small lesions. So in addition to the higher risk, Asian Americans having lower rates of screening, which is concerning and needs to be addressed.
Dr. Kim: Some 20 years ago when I went into colorectal surgery, the number of surgeries for colorectal cancer for Asian Americans was lower than for their white, Hispanic, or Black counterparts. Since then, that number has increased 12 times—not 12 percent—in America. On top of that, AAPI individuals are known to be less up to date on colorectal screening. Part of it could be a greater focus on other kinds of cancers—such as stomach and liver—instead, and part of it could be attributed to a tendency to play down illnesses and not be very good at following up with doctors.
Who should be thinking about screening? How often should it be done?
Dr. Chow: The United States Preventive Services Task Force (USPSTF), the body that sets guidelines for screening in the country, has recently updated their recommendation for women to start screening for breast cancer at the age of 40, every two years. However, there are other factors that could push one to start screening earlier or screen more frequently, and that is a conversation to have with a health care provider. These could include having a family history of breast cancer or having a genetic predisposition to breast cancer, such as a BRCA gene mutation.
Dr. Kim: The USPSTF recommends screening for colon cancer as early as the age of 45. Colonoscopies are the gold standard and would only have to be done every five to ten years. There are stool-based tests, which would have to be done every one to three years to provide comprehensive detection. This recommendation is the same for both men and women, although men have a higher prevalence of colon cancer. If a patient has a family history of cancer—could be of various types, including pancreas, stomach, liver, breast, endometrial or bladder—that person should consider early screening as well. A simple guideline would be: whatever age the family member had the cancer, the patient’s screening should be done at an age 10 years below that—thus for a patient whose family member had pancreatic cancer at age 50, the patient should get a colonoscopy at age 40.
What is involved in breast and colorectal cancer screenings? Is it painful/time-consuming?
Dr. Chow: The mammogram is the only screening method that has been shown to decrease mortality related to breast cancer. The best way to get a mammogram would be to get a referral from your primary care provider, or your OB/GYN. Under the Affordable Care Act (ACA), public and private insurance must provide preventive women’s health screening with no cost sharing. For those who do not have health insurance, there are ways to obtain low- or no-cost mammograms, as New York City and New York State have programs, such as free mammogram buses, that provide such screening.
The procedure itself is pretty simple, and a technician helps the patient position their breast in a machine that takes images of the breast tissue. Most women do not report significant pain—perhaps some discomfort as they might have to hold certain positions for imaging. But from start to finish, a patient could be in and out of the clinic in about 30 minutes.
Patient service representative Monet Douglas at the Mount Sinai Mammogram Screening Unit Truck
Dr. Kim: For stool-based tests, such as Cologuard®, a patient sends a stool sample to a lab, where it’ll be studied to see if it contains blood products and/or polyp components. However, such tests might miss some polyps, hence a need to do them more frequently. A colonoscopy, in which a tube with a camera is put into the rectum and colon, can not only discover polyps and cancerous tumors, but also treat and remove them. Under the ACA, colorectal cancer screening must be covered by public and private insurance without cost-sharing.
A colonoscopy does involve some preparation. The patient is instructed not to eat for about half a day, and to take a concoction that would rinse out the bowels. For the actual procedure, the patient is put to sleep and the doctor would examine the colon and rectum for polyps or signs of cancer. If polyps are removed, or cancer tumors are biopsied, there might be some pain or bleeding afterwards, but for most patients, colonoscopies are very well tolerated. The actual procedure itself takes about 30 minutes, although a patient might take an hour to recover after the exam.
What might be the consequences for not being vigilant about breast and colorectal cancer screening?
Dr. Chow: Missed breast cancer is the biggest consequence. By the time women feel a lump in their breast, the cancer is at a later stage, is harder to treat, and may have already spread to other parts of the body. The point of screening is to detect these cancers at an early stage, when they are still easily treatable and even curable. At an early stage, a patient is more likely to be offered breast conserving surgery, where only a portion of the breast is removed, rather than a mastectomy, where the entire breast is removed.
Dr. Kim: The thing about colon cancer is that it is a preventable cancer. If you can screen and detect signs before it presents as colon cancer, you can avoid more intensive treatment. When the cancer has penetrated into deeper layers of the colon, the surgery needed means you’ll lose more length of colon. If the cancer has advanced even more and spreads out of the colon, you will need not only surgery, but chemotherapy and radiation, and these are very intense on the body. For patients who get rectal cancer—that risk is higher for smokers—if not picked up early, there’s a chance to lose the anus, and that could mean needing a colostomy bag—a pouch in which stool comes out of the abdominal wall.
Any other advice for our AAPI communities to stay on top of their cancer screening?
Dr. Chow: I’ve noticed that some segments of the AAPI population might be less willing, or less able, to access health care. They should still try to form a close relationship with a primary care doctor, so that the doctor is aware of their risk factors and can advise them accordingly. For Asian Americans specifically, there’s a misconception that Asian women don’t get breast cancer as frequently. That’s not so true anymore, as the incidence of breast cancer has been steadily rising since 2000. And lastly, there’s a misconception that if a patient leads a healthy lifestyle, with no family history of breast cancer, they won’t get it. That’s great in that they’re at lower risk, but the majority of breast cancer cases are de novo, meaning the mutation happens for reasons we don’t know. If you meet the guidelines for breast cancer screening and have not done it, do seek it out as soon as you can.
Dr. Kim: I’ve noticed among my Asian patients that the cultural tendency of not wanting to speak up about pain or discomfort is actually working against them for their health. Keeping concerns to yourself hinders proper care. Another thing I’ve noticed is that some—usually older, immigrant individuals—trust their doctors too much and expect their doctors to know and handle everything, while others—sometimes younger, American-born individuals—don’t trust their doctors enough, might have a distrust of the system, or believe they know their body better than the doctor does. Either extreme is not good. The solution to break through to both is patient education and building trust. First, getting information out there about why cancer screening is important helps patients understand the risks. Then, the primary care doctor needs to build a close relationship with the patient, so that the patient actually goes to the screening, but just as importantly, trusts the doctor enough to come back for any follow-ups.