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 ColonColon CancerPolyp Polypectomy Colon Cancer Prevented!

5. Current Screening Options FOBT (on 3 consecutive stools) Yearly AND Flexible Sigmoidoscopy Every 5 Years Colonoscopy every 10 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 Region Age 50 and Over 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 32% Higher Incidence in Northern Plains American Indians AK/SW 6 fold Difference

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 Institutional Barriers -Discomfort with medical system -Discomfort with medical system -Physician not recommending -Physician not recommending -Unclear of risk -Unclear of risk -Competing priorities -Competing priorities -Time constraints -Time constraints -Endoscopic capacity -Distance to services No Screening No Preventative Polypectomy Later Stage Diagnoses??

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. 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 Traditionalism & Colorectal Cancer Screening among Reservation American Indians

10. 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 Traditionalism & Colorectal Cancer Screening among Reservation American Indians

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

12. 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.” Traditionalism & Colorectal Cancer Screening among Reservation American Indians

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

14. 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?” Traditionalism & Colorectal Cancer Screening among Reservation American Indians

15. 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?” Traditionalism & Colorectal Cancer Screening among Reservation American Indians

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

17. 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. Traditionalism & Colorectal Cancer Screening among Reservation American Indians

18. 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%) Traditionalism & Colorectal Cancer Screening among Reservation American Indians

19. 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) Traditionalism & Colorectal Cancer Screening among Reservation American Indians

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

21. Logistic Regression FOBTEndoscopy Traditional Healing Adjusted OR95%CI Adjusted OR95%CI Has ever been treated by a Traditional Native Healer 0.7(0.4, 1.1)1.1(0.7, 1.8) Uses traditional Native remedies/practices when ill 0.7(0.5, 1.1)0.6(0.4, 1.0) Uses traditional Native remedies/practices to prevent illness 0.7(0.4, 1.1)0.9(0.6, 1.4) None meet significance Traditionalism & Colorectal Cancer Screening among Reservation American Indians

22. Logistic Regression FOBTEndoscopy Number of traditional healing practices endorsed Adjusted OR 95%CIAdjusted OR 95%CI 01.0--1.0-- 10.6(0.3, 1.0)1.0(0.6, 1.6) 20.7(0.4, 1.4)0.6(0.3, 1.2) 30.6(0.3, 1.2)0.9(0.5, 1.8) p trend 0.060.41 Traditionalism & Colorectal Cancer Screening among Reservation American Indians

23. Logistic Regression FOBTEndoscopy Cultural Identity Adjusted OR 95% CI Adjusted OR 95% CI Uses American Indian language at home 0.8(0.6, 1.2)0.6(0.4, 0.9) Identifies with tribal tradition0.9(0.6, 1.5)0.7(0.4, 1.1) Actively participates in tribal events0.9(0.6, 1.3)0.8(0.5, 1.2) Traditionalism & Colorectal Cancer Screening among Reservation American Indians

24. Logistic Regression FOBTEndoscopy Number of cultural identity factors endorsed Adjusted OR 95% CI Adjusted OR 95% CI 01.0--1.0-- 10.6(0.3, 1.2)1.1(0.6, 2.1) 20.6(0.3, 1.0)0.7(0.4, 1.2) 30.7(0.4, 1.3)0.6(0.3, 1.1) p trend 0.36 <0.01 Traditionalism & Colorectal Cancer Screening among Reservation American Indians

25. 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 Traditionalism & Colorectal Cancer Screening among Reservation American Indians

26. 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 Traditionalism & Colorectal Cancer Screening among Reservation American Indians

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

28. 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 Traditionalism & Colorectal Cancer Screening among Reservation American Indians

29. 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 Traditionalism & Colorectal Cancer Screening among Reservation American Indians

30. Questions?