David G. Perdue

Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: a prospective multicenter observational cohort study.

Background There are few comparative data as to whether plastic or self-expanding metallic stents are preferable for palliating malignant hilar biliary obstruction. Methods Thirty-day outcomes of consecutive endoscopic retrograde cholangiopancreatographies performed for malignant hilar obstruction at 6 private and 5 university centers were assessed prospectively. Results Patients receiving plastic (N=28) and metallic stents (N=34) were similar except that metallic stent recipients more often had: Bismuth III or IV tumors (16/34 vs. 5/28 P=0.043), higher Charlson comorbidity scores (P=0.003), metastatic disease (P=0.006), and management at academic centers (P=0.018). The groups had similar rates of bilateral stent placement (4/28 vs. 5/34), and similar frequency of opacified but undrained segmental ducts (7/28 vs. 5/34). Adverse outcomes including cholangitis, stent occlusion, migration, perforation, and/or the need for unplanned endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography occurred in 11/28 (39.3%) patients with plastic versus 4/34 (11.8%) with metal stents (P=0.017). By logistic regression, factors associated with adverse outcomes included plastic stent placement (odds ratio 6.32; 95% confidence interval 1.23, 32.56) and serum bilirubin (1.11/mg/dL above normal: 1.01, 1.22) but not center type or Bismuth class. Conclusions Metallic stent performance was superior to plastic for hilar tumor palliation with respect to short-term outcomes, independent of disease severity, Bismuth class, or drainage quality.

Regional differences in colorectal cancer incidence, stage, and subsite among American Indians and Alaska Natives, 1999-2004.

Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality for American Indians and Alaska Natives (AI/ANs), but misclassification of race causes underestimates of disease burden.

Geographic Variation in Colorectal Cancer Incidence and Mortality, Age of Onset, and Stage at Diagnosis Among American Indian and Alaska Native People, 1990–2009

OBJECTIVES We characterized estimates of colorectal cancer (CRC) in American Indians/Alaska Natives (AI/ANs) compared with Whites using a linkage methodology to improve AI/AN classification in incidence and mortality data. METHODS We linked incidence and mortality data to Indian Health Service enrollment records. Our analyses were restricted to Contract Health Services Delivery Area counties. We analyzed death and incidence rates of CRC for AI/AN persons and Whites by 6 regions from 1999 to 2009. Trends were described using linear modeling. RESULTS The AI/AN colorectal cancer incidence was 21% higher and mortality 39% higher than in Whites. Although incidence and mortality significantly declined among Whites, AI/AN incidence did not change significantly, and mortality declined only in the Northern Plains. AI/AN persons had a higher incidence of CRC than Whites in all ages and were more often diagnosed with late stage CRC than Whites. CONCLUSIONS Compared with Whites, AI/AN individuals in many regions had a higher burden of CRC and stable or increasing CRC mortality. An understanding of the factors driving these regional disparities could offer critical insights for prevention and control programs.

The last frontier: innovative efforts to reduce colorectal cancer disparities among the remote Alaska Native population

BACKGROUND The Alaska Native (AN) population experiences twice the incidence and mortality of colorectal cancer (CRC) as does the U.S. white population. CRC screening allows early detection and prevention of cancer. OBJECTIVE We describe pilot projects conducted from 2005 to 2010 to increase CRC screening rates among AN populations living in rural and remote Alaska. DESIGN Projects included training rural mid-level providers in flexible sigmoidoscopy, provision of itinerant endoscopy services at rural tribal health facilities, the creation and use of a CRC first-degree relative database to identify and screen individuals at increased risk, and support and implementation of screening navigator services. SETTING Alaska Tribal Health System. PATIENTS AN population. INTERVENTIONS Itinerant endoscopy, patient navigation. MAIN OUTCOME MEASUREMENTS AN patients screened for CRC, colonoscopy quality measures. RESULTS As a result of these ongoing efforts, statewide AN CRC screening rates increased from 29% in 2000 to 41% in 2005 before the initiation of these projects and increased to 55% in 2010. The provision of itinerant CRC screening clinics increased rural screening rates, as did outreach to average-risk and increased-risk (family history) ANs by patient navigators. However, health care system barriers were identified as major obstacles to screening completion, even in the presence of dedicated patient navigators. LIMITATIONS Continuing challenges include geography, limited health system capacity, high staff turnover, and difficulty getting patients to screening appointments. CONCLUSIONS The projects described here aimed to increase CRC screening rates in an innovative and sustainable fashion. The issues and solutions described may provide insight for others working to increase screening rates among geographically dispersed and diverse populations.

Gallbladder Cancer Incidence Among American Indians and Alaska Natives, US, 1999-2004

Gallbladder cancer (GBC) is rare; however, it disproportionately affects the American Indian and Alaska Natives (AI/AN) population. The purpose of the study was to characterize GBC among AI/AN in the US population.

Mortality Caused by Chronic Liver Disease Among American Indians and Alaska Natives in the United States, 1999–2009

OBJECTIVES We compared chronic liver disease (CLD) mortality from 1999 to 2009 between American Indians and Alaska Natives (AI/ANs) and Whites in the United States after improving CLD case ascertainment and AI/AN race classification. METHODS We defined CLD deaths and causes by comprehensive death certificate-based diagnostic codes. To improve race classification, we linked US mortality data to Indian Health Service enrollment records, and we restricted analyses to Contract Health Service Delivery Areas and to non-Hispanic populations. We calculated CLD death rates (per 100,000) in 6 geographic regions. We then described trends using linear modeling. RESULTS CLD mortality increased from 1999 to 2009 in AI/AN persons and Whites. Overall, the CLD death rate ratio (RR) of AI/AN individuals to Whites was 3.7 and varied by region. The RR was higher in women (4.7), those aged 25 to 44 years (7.4), persons residing in the Northern Plains (6.4), and persons dying of cirrhosis (4.0) versus hepatocellular carcinoma (2.5), particularly those aged 25 to 44 years (7.7). CONCLUSIONS AI/AN persons had greater CLD mortality, particularly from premature cirrhosis, than Whites, with variable mortality by region. Comprehensive prevention and care strategies are urgently needed to stem the CLD epidemic among AI/AN individuals.

Primary liver cancer incidence among American Indians and Alaska Natives, US, 1999-2004

American Indians and Alaska Natives (AI/AN) experience higher morbidity and mortality from primary liver cancer than other United States (US) populations, but racial misclassification in medical records results in underestimates of disease burden.

A survey of indian health service and tribal health providers' colorectal cancer screening knowledge, perceptions, and practices

Background. Provider recommendation is critical for colorectal cancer (CRC) screening participation, yet few data exist on practices of providers serving American Indians and Alaska Natives. We examined Indian Health Service (IHS) and tribal provider practices, beliefs about screening efficacy, and perceptions of barriers.Methods. We developed a Web-based questionnaire and recruited respondents via electronic distribution lists. We generated descriptive statistics by region, provider type, and workplace setting.Results. Most respondents (77%) recommend starting CRC screening of average-risk patients at age 50; however, 22% recommend flexible sigmoidoscopy and 43% colonoscopy at intervals inconsistent with national guidelines. Of those recommending fecal occult blood test (FOBT), 23% use a single, in-office FOBT card as their only FOBT method. Respondents reported barriers to screening to include underutilized reminder systems and inadequate resources.Conclusions. Indian Health Service/tribal providers are knowledgeable about when to begin CRC screening; however, education about the appropriate use and frequency of CRC tests is needed.

Barriers to colorectal cancer screening among American Indian men aged 50 or older, Kansas and Missouri, 2006-2008.

American Indian (AI) men have some of the highest rates of colorectal cancer (CRC) in the United States but among the lowest screening rates. Our goal was to better understand awareness and discourse about colorectal cancer in a heterogeneous group of AI men in the Midwestern United States. Focus groups were conducted with AI men (N = 29); data were analyzed using a community-participatory approach to qualitative text analysis. Several themes were identified regarding knowledge, knowledge sources, and barriers to and facilitators of screening. Men in the study felt that awareness about colorectal cancer was low, and people were interested in learning more. Education strategies need to be culturally relevant and specific.

Hepatolithiasis and Cholangiocarcinoma in Cystic Fibrosis: A Case Series and Review of the Literature

Advancements in the pulmonary and infectious disease management of cystic fibrosis (CF) patients have led to a dramatic increase in the median life expectancy to 33 years, with children born today expected to reach their early 50 s [1, 2]. Liver disease is the third leading cause of CF-associated mortality, following pulmonary disease and transplant complications [1]. Autopsy studies have revealed a high prevalence of liver disease in CF patients, ranging from 10% in infants to 72% in adults [3, 4]. Multifocal biliary fibrosis and hepatic steatosis are the most common pathologic findings in CF liver disease, with secondary biliary cirrhosis, microgallbladder, cholecystitis, cholelithiasis, and sclerosing cholangitis also seen [5, 6].