status.26 In 2018, the median family income was $41,361 among blacks compared to $70,642 among NHWs, with 21% and 8%, respectively, living in poverty.27 People with the lowest socioeconomic status are 40% more likely to be diagnosed with CRC than those with the highest socioeconomic status.28 Close to half (44%) of this disparity is attributed to differences in the prevalence of risk factors associated with CRC (e.g., smoking, obesity)29 and a similar proportion is due to differences in CRC screening.30 After controlling for differences in risk factors, black individuals are no more likely than whites to develop adenomas or CRC, but are less likely to receive timely follow-up of a positive screening test and/or high-quality colonoscopy.31, 32 Higher CRC mortality among blacks may also reflect a larger proportion of tumors in the proximal colon.3 Importantly, the broad racial and ethnic groups to which cancer statistics are generally limited mask striking differences within these heterogeneous populations. For example, although CRC incidence in API men overall is 25% lower than in NHW men, rates in Japanese men are 23% higher.33 Even more alarming is the burden among Alaska Natives, who have the highest CRC incidence (89 per 100,000) and mortality (40 per 100,000) rates in the US, double those in blacks (46 and 19, respectively). CRC AI: American Indian, excluding Alaska; AN: Alaska Native. Rates are age adjusted to the 2000 US standard population. *Statistics based on data from Purchased/Referred Care Delivery Area (PRCDA) counties. AI/AN incidence rates exclude data from Kansas and Minnesota. Incidence rates for Alaska Native men and women are not statistically significantly different. Source: Incidence – NAACCR, 2019. Mortality – NCHS, 2019. ©2020, American Cancer Society, Inc., Surveillance Research Rate per 100,000 population Figure 5. Colorectal Cancer Incidence (2012-2016) and Mortality (2013-2017) Rates by Race/Ethnicity and Sex, US Non-Hispanic Black American Indian/Alaska Nativeexes combined Men Women Sexes combined Men Women 0 20 40 60 80 100 Sexes Men Women combined AN AI 89.0 40.7 85.1 92.9 46.4 36.1 0 10 20 30 40 50 Sexes Men Women combined AN AI 39.6 14.5 44.8 36.1 18.0 11.8 Incidence Mortality 6 Colorectal Cancer Facts & Figures 2020-2022 has been the most commonly diagnosed cancer in Alaska Natives since the early 1970s for reasons that are unknown, but may include a higher prevalence of CRC risk factors, such as a diet high in animal fat and low in fruits and vegetables, vitamin D deficiency, smoking, obesity, and diabetes.34, 35 In addition, Alaska Natives, particularly rural residents, have a high prevalence of Helicobacter pylori (H. pylori),36 a bacteria associated with inflammation and cancer of the stomach that may also be associated with CRC risk.37, 38 Despite a disproportionately high burden of advanced adenomas among Alaska Natives,39 the availability of endoscopic services in much of Alaska is inadequate.40, 41 A recent study found that Alaska had the lowest county-level CRC screening prevalence in the nation.42 In addition, the primary mode of screening at Indian Health Service facilities is stool testing, which has a limited capacity for cancer prevention and requires timely follow-up with colonoscopy for positive tests. Notably, AIANs are the only racial and ethnic group for which CRC mortality rates are not declining (see page 8). How has colorectal cancer occurrence changed over time? Incidence Despite higher incidence in men than in women, trends over time are very similar by sex (Figure 6). CRC incidence rates increased from 1975 through the mid-1980s, but since have generally decreased. The decline prior to 2000 is attributed equally to changing patterns in risk factors (e.g., reductions in smoking) and the uptake of CRC screening.43 However, the accelerated decline that began during the late 2000s is thought to predominantly reflect widespread uptake of CRC screening with colonoscopy, which increased among adults ≥50 years of age from 20% in 2000 to 61% in 2018.44 There is about a decade of lag time between the detection and removal of precancerous polyps through