Pulse
Driving Change
The incidence of colorectal cancer is especially high among American Indians in Minnesota. David Perdue is working to change that.
David Perdue is talking trucks. Sixty-foot, 18-wheel, million-dollar big-rigs. This is not a topic one would expect a gastroenterologist at the University of Minnesota Cancer Center to discuss, but Perdue is quick to explain that such a vehicle could be the key to reducing colorectal cancer among American Indians in the state—a population with an incidence rate that’s 68 percent higher than that for non-Hispanic whites, according to Minnesota Cancer Surveillance System figures.
Perdue lays out his vision, which involves converting a tractor-trailer into a mobile endoscopy unit that would bring affordable colonoscopy to reservations and other parts of the state with large American Indian populations. The idea for the mobile screening unit is part of Perdue’s mission to reduce suffering and death from this highly preventable disease among American Indians and improve their overall health.
A member of the Chickasaw Nation of Oklahoma, Perdue knew early in his career he wanted to do something to help Indian people. When he was a medical student at the University of Washington, he planned to go into primary care and work for the Indian Health Service (IHS). But during his first year of a med/peds residency at the University of Minnesota in 1999, he discovered gastroenterology. “I liked the mix of procedures and patient care,” he says. “And I realized GI diseases were a very large problem for the American Indian population—from GI malignancies to liver diseases to pancreatic diseases,” he says.
Perdue, however, didn’t realize the magnitude of colorectal cancer among American Indians in the state until two years ago when he started working with Jane Korn, M.D., M.P.H., medical director for the health promotion and chronic diseases division of the Minnesota Department of Health. Korn helped develop Minnesota’s Cancer Plan. Two of its priorities were to improve colorectal screening rates in the state and to reduce disparities for all cancer screenings among ethnic groups.
Perdue, who was finishing his fellowship at the time, began looking into colorectal cancer among American Indians here and elsewhere in the United States. He found few articles on the topic; most of the research was based on CDC or IHS mortality data. “The data were extraordinarily poor, and very little work had been done on barriers to care, or disparities in the treatment of survivors,” he says. “It was a wide-open field.”
The lack of good information prompted Perdue to get involved in a project linking the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database with those of the National Program of Cancer Registries and the IHS. His collaborative analysis of the combined data on colorectal cancer led to some surprising discoveries. In Alaska, for instance, the rate of colorectal cancer among Alaska Natives was double that for non-Hispanic whites. In the southwestern part of the country, however, the colorectal cancer rate for Indians was 60 percent lower than that for non-Hispanic whites.
Overall, they found a nearly five-fold difference in the incidence rates among native people from different regions of the United States. The southwestern region reported the lowest rate (21 cases per 100,000 persons), Alaska, the highest (102.6 cases per 100,000 persons). “That raises the important question of why,” Perdue says.
Circle of Evidence
Instead of attempting to answer that question, though, Perdue decided to put his energy into preventing the disease. He knew that by using colonoscopy to screen for and remove polyps, up to 90 percent of colorectal cancer cases could be avoided.
In the meantime, Korn applied for and received funding from the Cancer Research and Prevention Foundation to initiate a discussion about how to increase colorectal cancer screening among Indian populations in the state. She enlisted Perdue’s help with the project, and together they visited Minnesota’s 11 tribes to make their health directors and leaders aware of the prevalence of colorectal cancer and encourage them to participate in a discussion about how to prevent the disease. “We knew going into it that it was important for us to work with the tribes and not assume some kind of paternalistic role,” Perdue says.
Because Perdue was a physician and an American Indian, people listened to him. “He brought a different level of credibility to the discussion,” Korn says. “And he brought an incredible commitment to wanting to see something happen instead of just talking about it.”
Those visits led to the formation of the Minnesota Intertribal Colorectal Cancer Council, which includes tribal health officials, elders from urban and reservation Indian communities, and representatives from Mayo Clinic, the Minnesota Department of Health, the American Cancer Society, and the University of Minnesota Cancer Center.
At their first meeting in Bemidji, council members held a talking circle, a traditional Indian way of sharing ideas. Perdue asked whether colorectal cancer screening was happening in the Indian communities, why people didn’t get screened, and what they thought might improve acceptance of screening. The conversations yielded more information than the state or IHS could provide.
“We learned that there was not a lot of awareness even among public health nurses that colorectal cancer was happening to a great degree in these communities,” he says. He discovered that many people didn’t get screened unless they had symptoms or a strong family history of colorectal cancer. He heard health professionals say that fecal occult blood testing was available but not used often, that flexible sigmoidoscopy was rarely done in Indian health clinics, and that people had to leave the reservation to get a colonoscopy, the preferred screening.
And he heard tribe members tell about friends and neighbors who traveled to other communities for treatment. “Because of the stigma attached to cancer in native communities, people weren’t talking about it,” he says. Perdue explains that some tribal members still believe cancer is caused by breaking taboos or that it’s part of the Creator’s plan.
Perdue also found that doctors who treated tribal members weren’t aware of the high colorectal cancer rate in Minnesota. Perdue, who now conducts continuing medical education programs on the subject for physicians, says colorectal cancer among native people hasn’t gotten attention because nationally the incidence is 9 percent lower for American Indians and Alaska Natives than for non-Hispanic whites, according SEER data. But those numbers don’t tell the whole story. Perdue explains that the low prevalence in the southwestern part of the United States pulls the overall number down. And, he says, “American Indians are—as much as 40 percent of the time—misclassified as a different race in medical records. So national summary data from cancer registries underestimate the disease rate.”
Small Steps
A two-day Dialogue for Action Summit, which took place last September at Grand Casino Mille Lacs, brought together nearly 70 people, including members of the Minnesota Intertribal Colorectal Cancer Council, cancer researchers, representatives from the IHS, tribal physicians and health directors, cancer survivors, and representatives from the state and the American Cancer Society, to come up with strategies for getting more people screened.
Since then, Perdue, who co-chaired the summit, says physicians from several tribal health systems have made colorectal cancer screening a higher priority, and some of the tribes have changed their health insurance plans for casino employees to include colorectal cancer screening as a preventive service. In addition, five tribes have passed resolutions to make screening a priority.
Perdue and others testified before the Minnesota Legislature this spring in support of a bill that would have provided state money for colorectal cancer screening for the uninsured and underinsured. More than half of the American Indians in Minnesota don’t live on reservations and lack access to tribal clinics, according to U.S. Census data; those individuals might have benefited had such a program become law.
Right now, Perdue is concentrating on making his case for a mobile endoscopy unit. He has been meeting with tribal health directors about everything from how to bill for such services to where to park a truck so it can be hooked up to electrical service to how to involve local physicians in the project. His next step is to put together a business plan and look for funding.
“We know taking polyps out prevents colorectal cancer,” he says, explaining his focus. “We have a procedure to prevent cancer, and it makes sense to see where we can go with that.”—Kim Kiser